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Columbia  JMwafftp 
intijeCttpofJtogork 

College  of  $i)pgictan£i  ano  gmrgeong 
Hibrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/manualofoperativ1895stim 


A  MANUAL 


OPERATIVE   SURGERY. 


BY 


LEWIS  A.  STIMSON,  B.A.,  M.D., 

SURGEON  TO  THE  NEW  YORK,  BELLEVUE,  AND  HUDSON  STREET  HOSPITALS  ;  PROFESSOR 

OF  SURGERY  IN  THE  UNIVERSITY  OF  THE  CITY  OF  NEW  YORK  ; 

CORRESPONDING   MEMBER   OF    THE  SOCIETfc 

DK  CHIRURGIE,  PARIS. 


AND 


JOHN  ROGERS,  Jr.,  B.A.,  M.D., 

ASSISTANT    DEMONSTRATOR    OF    ANATOMY    IN    THE    COLLEGE    OF    PHYSICIANS    AND 

SURGEONS  (COLUMBIA  COLLEGE),  NEW  YORK  ;   SURGEON  OF  THE 

OUT-PATIENT  STAFF,   HUDSON  STREET  HOSPITAL. 


TH  IRD    EDITION 


WITH    THREE  HUNDRED   AND    THIRTY-FOUR   ILLUSTRATIONS. 


PHILADELPHIA: 

LEA    BROTHERS    &    CO. 

1895. 


^D 


St*> 
Iff*)*' 


Entered  according  to  the  Act  of  Congress,  in  the  year  1S95,  by 

LEA  BROTHERS  &  CO., 
In  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


PHIJ.AhKU'IUA  : 
HO  UNA  N,    PKINTKR. 


PREFACE  TO  THIRD  EDITION, 


In  the  preparation  of  this  third  edition,  it  has  been  found 
necessary  almost  wholly  to  rewrite  the  book  in  order  to  note 
the  important  changes  that  have  taken  place  during  the  last 
ten  years  in  the  planning  and  execution  of  many  of  the 
operations  that  have  been  preserved,  to  substitute  others,  and 
to  make  the  numerous  additions. 

Of  the  operations  formerly  in  vogue,  a  number  have  been 
left  out  because  they  had  their  origin  and  found  their  useful- 
ness only  in  conditions  and  dangers  of  the  process  of  repair 
that  are  now  rarely  met  with,  and  others  because  superior 
substitutes  have  been  introduced.  The  most  important  addi- 
tions and  modifications  have  been  made  in  the  surgery  of  the 
cranium  and  of  the  abdomen. 

To  Dr.  Rogers  has  fallen  all  the  labor  of  collecting  and 
making  the  descriptions,  seeking  and  verifying  references, 
obtaining  the  cuts  and  drawings,  and  of  composition.  He 
had  my  advice  and  assistance  in  the  selection  of  subjects,  and 
I  revised  the  manuscript  before  publication  and  read  all  the 
proof. 

LEWIS  A.  STIMSON. 

New  York, 

34  East  Thirty -third  Street, 

October,  1895. 


CONTENTS. 


PART  I. 

THE 

ACCESSORIES   OF   AN   OPERATION. 

PAGE 

PAGE 

Anaesthesia , 

13 

Sutures,  Twisted, 

22 

Local, 

13 

Preparation  of  materials  used 

in  an 

General, 

14 

operation, 

23 

Administration   of 

ihe 

anaes- 

Catgut, 

23 

thetic, 

15 

chromicized, 

24 

Rectal, 

16 

Silk, 

24 

Arrest  of  hemorrhage, 

17 

Silkworm  gut, 

24 

Ligature, 

17 

Sponges, 

24 

Torsion, 

18 

Absorbent  gauze, 

24 

Pressure, 

19 

Bichloride  gauze, 

25 

Cold  or  heat, 

19 

Iodoform  gauze, 

25 

Position, 

19 

Drainage-tubes, 

25 

Artificial  ischsemia, 

19 

Absorbent  cotton, 

26 

Sutures, 

21 

Rubber  tissue, 

26 

Interrupted, 

21 

Sterilization, 

26 

Continuous, 

22  '  The  wound  and  its  treatment, 

27 

PAE 

r  ii. 

LIGATURE   OF   ARTERIES. 


General  directions,  30 
Anatomy  of  the  supra-clavicular 

region,  33 

Ligature  of  the  innominate  artery,  34 

Anatomy,  34 

Operation,  35 

Ligature  of  the  subclavian  artery,  36 

1st  portion,  left  subclavian,  37 

1st  portion,  right  subclavian,  37 

2d  portion,  37 

3d  portion,  38 

Ligature  of  the  superior  thyroid,  39 

Ligature  of  the  inferior  thyroid,  39 

Ligature  of  the  vertebral  artery,  40 

Ligature  of  the  axillary  artery,  41 

Under  the  clavicle,  41 

In  the  axilla,  41 

Ligature  of  the  brachial  artery,  43 

Anatomy,  43 

Operation,  44 

Ligature  of  the  radial  artery,  45 

Anatomy,  45 

Operation,  upper  third,  45 

Operation,  lower  third,  46 

Ligature  of  the  ulnar  artery,  46 

Anatomy,  46 

Operation  at  the  junction  of  the 

upper  and  middle  thirds,  46 

Operation  in  the  lower  third,  47 


Ligature  of  the  common  carotid,  47 
At  the  place  of  election,  47 
Ligature  of  the  external  carotid,  48 
Anatomy,  49 
Operation,  51 
Ligature  of  the  internal  carotid,  51 
Ligature  of  the  lingual  artery,  51 
Anatomy,  51 
Operation,  52 
Ligature  of  the  facial  artery,  53 
Ligature  of  the  occipital  artery,  53 
Ligature  of  the  temporal  artery,  54 
Ligature  of  the  abdominal  aorta,  54 
Ligature  of  the  common  iliac,  55 
Anatomy  of  the  common,  inter- 
nal, and  external  iliac  arteries,  55 
Extra-peritoneal,  56 
Intra-peritoneal,  57 
Ligature  of  the  internal  iliac,  57 
Ligature  of  the  external  iliac,  5S 
Ligature  of  the  gluteal,  sciatic,  and 

internal  pudic  arteries,  59 
Ligature  of  the  femoral  artery,  60 
Anatomy,  60 
Operation,  61 
At  the  apex  of  Scarpa's  tri- 
angle, 61 
In  the  middle  of  the  thigh,  61 
In  Hunter's  canal.  '62 


CONTENTS. 


Ligature  of  the  popliteal  artery, 
Ligature  of  the  anterior  tibial, 

Anatomy, 

Operation, 
Ligature  of  the  dorsalis  pedis, 


PAGE 

62 
63 
63 
63 
65 


PAGE 

Ligature  of  the  posterior  tibial,  65 

Guthrie's  method,  65 

Lateral  method,  65 

In  the  lower  third  and  behind 

the  ankle,  67 


PART  III. 


AMPUTATIONS. 


Circular  method, 
1st  time, 
2d  time, 

(6)  Alanson's  method, 

(c)  Cutaneous  sleeve, 
3d  time. 

Oval  method, 

Flap  method, 

Skin  flaps  and  circular  division, 

Long  anterior  flap, 

Teale' s  method, 

Amputation  of  the  fingers, 

Phalanges, 

Through  the  metacarpo-phalan- 
geal  articulation, 
Amputation  of  the  metacarpal 

bones, 
Amputation  at  the  wrist, 

Circular  method, 

Antero-posterior  flaps, 
External  lateral  flap, 
Amputation  of  the  forearm, 
Amputation  at  the  elbow-joint, 

Anterior  flap, 

(a)  The  joint  opened  from 
behind, 

(d)  The  joint  opened  from 
in  front, 

Lateral  flap, 

Circular, 
Amputation  of  the  arm, 
Amputation  at  the  shoulder-joint, 

General  considerations, 

Oval  method  (Baron  Larrey), 

Double  flap  method  (Lisfranc), 

Spencc's  method, 
Amputation  of  the  arm,  scapula, 

and  clavicle, 
a  mputation  of  the  toes, 

Distal  phalanx  of  the  great  toe, 

Disarticulation  of  the  great  toe, 

Two  adjoining  toes, 
Amputation  of  a  metatarsal  bone, 

Disarticulation  of  the  1st  or  5th 
metatarsal 
Disarticulation  of  all  the  metatarsal 
bones  (Lisfranc's  amputation), 

Modifications, 
Medio-tarsal  amputation  (Chopart), 

Triplets, 


Sub-astragaloid  amputation, 

94 

Amputation  at  the  ankle-joint 

(Syme), 

95 

Modifications, 

98 

A.    Internal    lateral    flap 

(Roux), 

98 

B.  Pirogoft's  amputation, 

99 

Comparison  of  the  different  meth- 

ods ot  partial  and  total  ampu- 

tation of  the  foot, 

102 

Amputation  of  the  leg, 

102 

A.  Lower  third, 

102 

1.  Circular  method, 

104 

Bran's 

104 

2.  Modified  circular, 

101 

3.  Long  anterior  flap  (Bell), 

104 

4.    Elliptic    posterior  .  flap 

(Guyon), 

105 

B.  Middle  third, 

106 

1.  Long  anterior  curved  flap 

106 

2.  Single  posterior  flap, 

106 

3.  Skin  flaps  and  circular 

division, 

106 

C.  Upper  third, 

107 

1.  Long  anterior  rectangu- 

lar flap  (Teale), 

107 

2.  Long  posterior  rectangu- 

lar flap  (Lee), 

108 

3.  Modified  flap  (Bell), 

108 

Large  external  flap, 

108 

Comparison  of  the  different  meth- 

ods, 

109 

Amputation  at  the  knee, 

110 

A.  Disarticulation, 

110 

Lateral  flaps, 

111 

B.  Amputation  through  the 

condyles,  oval       , 

111 

Anterior  flap  (Carden), 

111 

Gritti's  modification, 

112 

Amputation  of  the  thigh, 

114 

Teale  and  Carden, 

115 

Modified  flap,  in  lower  third 

(Syme), 

115 

Long  anterior  flap, 

115 

Circular, 

116 

Amputation  at  the  hip-joint, 

117 

Anterior  racket  or  oval, 

119 

External    racket  or  modified 

oval, 

120 

Anterior  flap, 

121 

CONTENTS. 


VII 


PART    IV. 


EXCISION   OF    JOINTS    AND    BONES. 


General  considerations, 
Major  articulations, 
Excision  of  the  shoulder-joint, 
Ollier's  method, 
Von  Langenbeck's  method 
By  a  transverse  incision, 
Excision  of  the   head  of  the 
scapula, 
Excision  of  the  elbow-joint, 

Central  longitudinal  incision 

(v.  Langenbeck), 
Ollier's  method, 
Nelaton's  method, 
Long  radical  incision  (Hueter), 
Osteoplastic  method, 
Bilateral  incisions,  Vogt, 
Partial  excision, 
Excision  of  anchylosed  elbow, 
Ollier's  method, 
P.  Heron  Watson's  method, 
Operative  reduction  of  old  disloca- 
tion, 
Excision  of  the  wrist, 

Bilateral  incisions  (Lister), 
Radial  incision  (Oilier), 
Dorso-radial  incision  (Von  Lan- 
genbeck), 
Excision  of  the  hip-joint, 
Say  re's  method, 
Ollier's  method, 
Langenbeck, 
Anterior  incision, 
Arthrectomy, 
Anchylosis  of  the  hip-joint,  treated 
by  subcutaneous  division  of 
the     neck    of    the    femur 
(Adams), 
Division  below  the  trochanter, 
Excision, 
Excision  of  the  knee-joint, 
Semilunar  incision, 
Transverse  incision, 
Arthrectomy, 
Excision  of  the  ankle-joint, 

Vogt's  method  by  removal  of 

the  astragalus, 
Osteoplastic   excision  of  foot 
(Mikulicz), 
Operative  reduction  of  old  Pott's 

fracture, 
Excision  of  the  bones  and  smaller 

articulations, 
Excision  of  the  superior  maxilla, 
Operation  by  a  median  inci- 
sion, 
Subperiosteal  excision  (Oilier), 
Excision  of  lower  portion, 
Excision  of  upper  portion, 
Simultaneous    excision    of   both 

superior  maxillae, 
Partial  and  temporary  excisions  of 
the  superior  maxilla  to  facili- 
tate the   removal   of   naso- 
pharyngeal polyps, 


PAGE 

PAGE 

124 

Partial  osteoplastic  resection  of  ante- 

127 

rior  portion  of  hard  palate 

127 

(Chalot), 

170 

128 

Resection  of  the  upper  portion 

129 

(Von  Langenbeck), 

171 

130 

Other  methods  of  gaining  access  to 
the    pharynx    through    the 

130 

nose, 

172 

131 

Boeckel, 

172 

Oilier, 

173 

132 

Excision  of  the  inferior  maxilla, 

174 

133 

General  considerations, 

174 

134 

Resection  of  the  anterior  por- 

134 

tion  of  the  body, 

176 

135 

Resection  of  the  lateral  por- 

136 

tion  of  the  body, 

177 

137 

Resection  of   the   ramus  and 

137 

half  the  body, 

177 

137 

Excision  of  the  entire  bone, 

178 

138 

Subperiosteal  method, 

178 

Partial  excisions, 

179 

139 

Anchylosis  of  the  jaw, 

179 

140 

Excision  of  the  condyle, 

180 

141 

Resection  of  the  sternum, 

180 

144 

L- 

Resection  of  the  ribs, 

Estlander's   operation  for  em- 

181 

145 

pyema. 

is; 

146 

Excision  of  the  clavicle, 

182 

146 

Excision  of  the  scapula, 

183 

147 

Subperiosteal  method  (Oilier), 

184 

148 

Opening  of  the  joint, 

185 

148 

Partial  excisions  of  the  scapula, 

186 

149 

Resection  of  the  humerus, 

186 

Upper  portion, 

186 

Middle  portion, 

186 

Lower  portion, 

186 

150 

Total  excision, 

187 

151 

Excision  of  the  ulna. 

187 

152 

Excision  of  the  radius, 

187 

152 

Partial  excisions  of  the  ulna 

153 

and  radius, 

187 

154 

Excision  of  the  metacarpal  bones 

155 

and  phalanges, 

188 

155 

Resection  of  a  phalanx, 

188 

Resection  of  the  bones  of  the  pelvis, 

18S 

157 

Excision  of  the  coccyx, 

189 

Resection  of  the  shaft  of  the  femur, 

189 

159 

Resection  of  the  shaft  of  the  tibia, 

190 

Resection  of  the  fibula, 

191 

161 

Of  its  upper  extremity, 

192 

Of  the  lower  portion, 

192 

162 

Excision  of  the  entire  fibula, 

192 

162 

Excision  of  the  bones  of  the  foot, 

193 

Calcaneum, 

193 

164 

A.  Holmes's  method, 

193 

166 

B.  Subperiosteal     method 

167 

(Oilier), 

194 

16S 

C.  Farabeuf, 

195 

Astragalus, 

196 

169 

Ollier's  method, 

196 

When  dislocated, 

196 

When  shattered, 

196 

Metatarsal    bones    and    pha-, 

169 

langes, 

197 

Ylll 


CONTENTS. 


Trephining, 

Of  the  cranium, 

General  considerations, 
Temporary,  by  omega  flap, 
Craniectomy," 
For  fracture, 
Relation  of  brain  to  overlying 

parts  (Reid), 
Relation  of  brain  to  overly  in 

parts  (Kocher), 
Position  of  lateral  sinus, 
To  open  lateral  sinus, 


iGE 

PAGE 

197 

Trephining— 

197 

For  cerebral  abscess  due  to  mid 

197 

die-ear  disease, 

211 

200 

Of  cerebellum, 

212 

202 

Puncture  of  lateral  ventricles, 

213 

202 

For  middle  meningeal  hemor- 

rhages, 

213 

203 

Resection  of  fifth  nerve  within 

the  skull, 

215 

207 

Of  the  frontal  sinus, 

216 

209 

Of  the  antrum, 

216 

210 

PART  V. 


NEUROTOMY    AND   TENOTOMY. 


Division  and  resection  of  nerves, 
Supra-orbital  nerve, 

Subcutaneous  division, 

Excision  of  a  portion, 

A.  Above  the  eyebrow, 

B.  Below  the  eyebrow, 
Supra-trochlear  nerve, 

Superior  maxillary  nerve, 

A.  Division  of  the  nerve  on  the 

face, 

1.  Subcutaneously, 

2.  Through  the  mouth, 

3.  By  external  excision, 

B.  Resection    of     the     infra- 

orbital portion, 
Tillaux's  method, 
Malgaigne's  method, 
Lticke's  method, 
Inferior  dental  nerve, 

A.  At  the  mental  foramen, 

B.  Within  the  canal, 

C.  Before   its   entry   into   the 

canal, 

1.  From  within  the  mouth, 

2.  Through  the  cheek, 
At  the  foramen  ovale. 

Buccal  nerve, 
Lingual  nerve, 


217 

Lingual  nerve,  Moore's  method, 

226 

217 

Facial  nerve, 

227 

218 

Brachial  plexus, 

227 

218 

Posterior  roots, 

228 

218 

Cervical  plexus, 

228 

218 

Spinal  accessory, 

229 

219 

First,  second,  and  third  nerves  for 

219 

wry-neck, 

229 

Median  nerve, 

230 

219 

Ulnar  nerve, 

231 

220 

Musculo-spinal  nerve, 

231 

220 

Great  sciatic  nerve, 

232 

220 

Internal  popliteal  nerve. 

232 

External  popliteal  nerve, 

232 

220 

Anterior  crural  nerve, 

232 

220 

Neurorrhaphy, 

232 

221 

Tenotomy," 

233 

221 

General  considerations, 

233 

222 

Tendo-Achillis, 

234 

222 

Tibialis  posticus, 

234 

223 

A.  Above  the  malleolus, 

235 

B.  On  the  side  of  the  foot. 

235 

223 

Tibialis  anticus, 

235 

223 

Peronei, 

235 

223 

Flexor  tendons  at  the  knee, 

235 

221 

Sterno-cleido-mastoid, 

235 

22.', 

Levator  palpebral, 

235 

226 

Tenorrhaphy, 

236 

MIKCKLLANICOLS    OPKRATION8. 


Thiersch's  skin  grafting,  238 

lie  tumors,  240 

Birth-mark,  242 

Separation  of  web-lingers,  243 

Cicatricial  Bexlon  of  phlanges,  244 

Dupuytren'a  contraction,  215 

ingrown  toenail,  245 

Removal  of  cervical  glands,  247 

O.-teotomy,  249 

Femur,  249 

Maccwen,  260 


Osteotomy,  femur,  Ogston,  251 

Tibia,  252 

For  hallux  valgus,  252 

( lunelform,  for  talipes,  258 

Operations  for  ununited  fracture,      256 

Suture  of  patella,  257 

Open  method,  257 

M'<liate  silk  ligature,  258 

Suture  of  olecranon,  258 

Laminectomy,  259 


CONTENTS. 


IX 


PART  VI. 


PLASTIC   OPERATIONS   ON   THE   FACE. 


The  different  methods  and   their 

Rhinoplasty — 

history, 

261 

B 

Ollier's  osteoplastic  me- 

G'. neral  principles, 

262 

thod, 

288 

Cheiloplasty, 

263 

C 

Alquie's  method, 

290 

A.  Lower  lip, 

263 

D 

Italian  method. 

290 

1.  V-incision, 

263 

Operations  upon  the  eyelids, 

291 

2.  Oval  horizontal  incision. 

264 

Bleph 

aroraphy, 

291 

3.  Method    of    Celsus    or 

Canthoplasty, 

292 

Serres, 

265 

Blepharoplasty, 

293 

4.  Dieffenbach, 

266 

1. 

In  ectropion. 

293 

5.  Syme-Buchanan, 

266 

Wharton  Jones. 

293 

6.  Buck's  method, 

266 

Alphonse  Guerin, 

294 

7.  Square  lateral  flaps,  Mal- 

Von  Graefe, 

294 

gaigne, 

269 

Dieffenbach,      Adams, 

8.  Square  vertical  flaps, 

269 

and  Ammon, 

295 

B.  Angle   of  the  mouth    (sto- 

Richet, 

295 

matoplasty), 

270 

Knapp, 

296 

Buck, 

270 

Burow, 

296 

C.  Upper  lip, 

271 

Dieffenbach, 

297 

1.  Vertical  flaps, 

272 

Indian  method, 

297 

2.  Infero-lateral  flap, 

272 

Richet, 

298 

Harelip, 

273 

Hasner  d'Artha, 

298 

Single  harelip,  simple, 

273 

Denonvilliers, 

299 

1,  Double  flaps, 

273 

Ectropion  due  to  excess 

2.  Nelaton's  method, 

274 

of  conjunctiva, 

300 

3.  Single  flap. 

275 

2. 

Entropion, 

300 

4.  Giraldes's  method, 

275 

Canthoplasty, 

300 

Double  harelip,  simple, 

276 

Ligature, 

300 

Complicated  harelip, 

276 

Excision  or  cauteriza- 

Rhinoplasty, 

278 

tion  of  a  fold  of  the 

1.  Superficial   defect,    not   in- 

skin, 

300 

volving  the  bones  or  sep- 

Spasmodic   entropion, 

tum, 

279 

Von  Graefe, 

301 

Lateral,  oblique,  and  ver- 

Excision of  a  portion  of 

tical  flaps, 

279 

the  orbicularis. 

301 

Denonvillier's  method, 

280 

Division  of  tarsal  carti- 

Von Langenbeck's  method, 

280 

lage, 

302 

Michon's  method, 

281 

Vertical  division. 

302 

Restoration  of  columna, 

281 

Longitudinal  divi- 

2. Loss  of  the  septum  and  nasal 

sion  (Ammon), 
Excision  of  part  of  tar- 

302 

bones,  the  skin  remain- 

ing entire, 

281 

sal  cartilage, 

302 

Dieffenbach's  case, 

282 

3. 

Symblepharon, 

303 

Ollier's    osteoplastic    me- 

Ligature, 

303 

thod, 

283 

Arlt's  method, 

303 

Double  layer,  or  superposed 

Teale's  method, 

304 

flaps, 

284 

Ledentu's  method, 

304 

Pancoast's     subcutaneous 

4. 

Pterygion, 

305 

method, 

285 

Excision, 

305 

3.  Loss  of  more  or  less  of  the 

Ligature, 

305 

surface  and  the  septum, 

286 

5. 

Trichiasis. 

306 

A.  Indian  method, 

2S6 

Von  Graefe, 

306 

Modifications, 

287 

Anagnostakis, 

306 

CONTENTS. 
PAST  VII. 

SPECIAL   OPERATIONS. 


CHAPTER  I. 

OPERATIONS    UPON  THE  EYE  AND  ITS  APPENDAGES. 


PAGE 

The  cornea,  307 

Removal  of  a  foreign  body,  307 

Puncture  of  the  cornea,  308 

Evisceration  for  staphyloma,  30S 

The  iris,  310 

Iridotomy,  310 
Simple  incision  (Cheselden, 

Bowman),  311 
Simple  iridotomy,  Wecker,  311 
Double  iridotomy,  Wecker,  311 
Iridectomy,  311 
Anciphlogistic  iridectomy,  312 
Iridesis,  315 
Corelysis,  316 
Operations  undertaken  for  the  re- 
lief of  cataract,  317 
Depression  or  couching,  317 
Scleronyxis,  318 
Keratonyxis,  318 
Division,  Discission,    or   Solu- 
tion. 319 
Division  through  the  cor- 
nea, 320 
Division  through  the  scle- 
rotic (Hays),  320 
Extraction,  321 
Flap  extraction,  321 
Von  Graefe's  method,  325 


Operations  undertaken  for  the  re- 
lief of  cataract — 

Gayett  and  Knapp,  327 

Linear  extraction,  328 

Scoop  extraction,  328 

Removal  by  suction,  330 
Removal  of  the  lens  in  its 

capsule,  330 
Pagenstecher's  method,  331 
Secondary  cataract,  331 
Operations  for  the  relief  of  stra- 
bismus, 332 
Internal  rectus,  333 
Subconjunctival  method,  334 
Secondary  strabismus,  335 
Enucleation  of  the  eyeball,  335 
Extirpation  of  the  contents  of 
the  orbit,  336 
Operations  upon  the  lachrymal  ap- 
paratus, 336 
Extirpation  of  the  lachrymal 

gland,  336 
Lachrymal    sac,     duct,     and 

canaliculi,  337 

Slitting  up  the  canaliculus,  33H 

Puncture  of  the  sac,  339 

Stricture  of  the  nasal  duct,  340 


CHAPTER  II. 

OPERATIONS  UPON  THE  EAR  AND    ITS  APPENDAGES. 


Occlusion  of  the  external  auditory 

canal,  340 

Introduction  of  speculum,  341 

Paracentesis  of  the  drum-head,  341 


Catheterization  of  the  Eustachian 

tube,  341 

Opening  of  mastoid  antrum,  342 


CHAPTER  III. 

OPERATIONS  UPON  THE    MOUTH   AND  PHARYNX. 


Excision  of  the  tonsils,  344 

Staphyloraphy,  345 

Uranoplasty,  351 

Ferguson's    osteoplastic    me- 

thod.  354 

Lannelongue's  method,  355 

Excision  of  the  tongue,  355 

Through  the  mouth,  356 


Excision  of  the  tongue— 

Kocher, 

SC-aedillot's  method, 
Division  <il'  the  fiu:iium, 
Ranula, 
Salivary  fistula, 

Degoise's  method, 

Van  liuren'smctlioil, 


358 
359 
361 
861 
861 
362 
362 


CHAPTER  IV. 

OPERATIONS  PERFORMED  UPON  THE  NECK. 


Broncbotomy,  363 

Subhyoid  laryngotomy,  868 

Thyroid  laryngotomy.  865 

Crico-tbyroid  (aryngotomy,  365 

l.iiryngo-trucheotomy,  366 


Laryngotracheotomy— 

De  Saint  Germain's  method,    367 
Tracheotomy,  367 

By    galvano-    or    thermo- 
cautery, 870 


Laryngectomy, 

Complete, 

Partial, 
Pharyngectomy, 

Von  Langenbeck, 

Mikulicz, 

Cheever, 


ONT, 

ENTS. 

xi 

PAGE 

PAGE 

370 

CEsophagotomy, 

375 

370 

Internal, 

375 

371 

External, 

376 

372 

Operations  upon  thyroid  gland, 

378 

373 

Ligation  of  arteries, 

380 

373 

Enucleation  of  a  portion; 

380 

374 

Removal  of  a  portion, 

380 

Removal  of  isthmus, 

382 

CHAPTER  V. 

OPERATIONS   PERFORMED  UPON  THE  THORAX. 


Amputation  of  the  breast, 
Paracentesis  of  the  thorax, 


382  ;  Paracentesis  of  the  pericardium,       384 
383 


CHAPTER  VI. 

OPERATIONS  PERFORMED    UPON  THE  ABDOMINAL  WALL, 
STOMACH,  AND   INTESTINES. 


Paracentesis  of  the  abdomen, 

385 

Herniotomy,  kelotomy— 

Laparotomy,    ■ 

386 

Strangulated  inguinal  hernia, 

432 

Operations  on  the  intestines, 

389 

Femoral  hernia, 

434 

Anatomy, 

389 

Umbilical  hernia, 

435 

Continuous  suture, 

391 

Obturator  hernia, 

437 

Right-angled  continuous, 

391 

Radical     cure     of     inguinal 

Interrupted  (Lembert), 

392 

hernia, 

437 

Czerny, 

393 

Czerny, 

437 

Halsted's  quilt  suture, 

394 

Bassirii, 

439 

Circular  enterorrhaphy, 

394 

Halsted, 

444 

Intestinal  anastomosis, 

396 

McBurney, 

444 

Senn's  plates, 

398 

Radical     cure    of    umbilical 

Murphy's  button, 

400 

hernia, 

445 

Ileo  sigmoidestomy, 

400 

Radical  cure  of  femoral  hernia, 

445 

By  intussusception, 

401 

Operations  upon  the  rectum, 

446 

Enterotomy, 

402 

Imperforate  anus  or  rectum, 

447 

Right  inguinal, 

402 

Prolapse, 

449 

Colotomy, 

403 

Rectopexy, 

450 

Right  inguinal, 

405 

Ablation, 

451 

Median, 

405 

Torsion, 

451 

Lumbar, 

405 

Rectotomy, 

451 

Closure  of  an  artificial  anus  or 

Fistula, 

452 

fecal  fistula, 

407 

Hemorrhoids, 

453 

Removal    of    vermiform    ap- 

Ligation, 

453 

pendix, 

409 

Whitehead, 

453 

McBurney, 

410 

Excision  of  anus  and  part  of 

During  period  of  suppura- 

rectum, 

453 

tion, 

410 

A.  Removal  from  below, 

454 

Stomach, 

412 

B.  Removal    from    below, 

Gastrostomy, 

413 

leaving  sphincter, 

456 

Gastrotomy, 

416 

C.  Hueter's  method, 

457 

For  stenosis  of  pyloric  or 

D.  Removal  from  behind, 

cardiac  orifice, 

418 

Kraske, 

458 

Gastrorrhaphy, 

420 

Liver, 

461 

Pylorectomy, 

421 

Abscess, 

462 

Gastroenterostomy, 

423 

Hydatids, 

464 

Jejunostomy, 

425 

Cholecystostomy , 

465 

Herniotomy,  kelotomy, 

426 

Operations  on  bile  ducts, 

466 

General  directions, 

427 

Cholecysteuterostomy, 

467 

A.  Recognition  of  the  sac 

Cholecystectomy, 

469 

and  bowel, 

427 

Spleen, 

469 

B.  Opening  of  the  sac, 

428 

Splenectomy, 

470 

C.  Division  of  the  stricture, 

428 

Kidney, 

470 

D.  Examination  and  return 

Exposure  of, 

471 

of  the  bowel, 

429 

Lumbar  methods, 

471 

E.  Treatment  of  the  omen- 

Nephrotomy, 

474 

tum, 

431 

Nephrolithotomy, 

475 

\11 


CONTENTS. 


Kidney- 
Lumbar  nephrectomy,  176 
Abdominal  nephrectomy,  177 
Nephropexy,  479 


Ureter, 

Operations  on, 
Wounds  of, 


TAGE 

479 
480 
482 


CHAPTER  VII. 

OPERATION'S  UPON  THE  GENITO-URINARY  ORGANS  OP  THE  MALE. 


i  ust ration.  483 

Hydrocele,  485 

Puncture  of  the  sac,  485 

Radical  cure,  486 

Varicocele,  486 

Excision  of  the  scrotum,  487 

Subcutaneous  ligature,  487 

Open  ligation,  487 

Amputation  of  the  penis,  l.s.s 

( (iterations  for  phimosis,  489 

Dorsal  incision,  489 

Circumcision,  490 

Paraphimosis,  493 

Division  of  the  frscnum,  494 

Epispadias,  494 

Ni-laton's  method,  494 

Thiersch's  method,  496 

Hypospadias,  498 

Urethroplasty,  500 

Theophile  Auger's  method,  500 

Duplay's  method,  502 

Urethral  fistula,  503 

General  considerations,  503 

Urethroraphy,  505 

Urethroplasty,  505 

Ni'laton's  method,  506 

I  Icy  bard,  Dieffenbach,  and 

Kelore,  506 

Delpech  and  Alliot,  507 


Urethral  fistula- 
Sir  Astley  Cooper,  507 
Arlaud,  507 
Sedillot,  507 
Rigaud,  507 
Theophile  Anger,  508 
Scymanowski,  508 
McBurney,  508 
Internal  urethrotomy,  508 
External  perineal  urethrotomy,  510 

A.  With  a  guide,  510 

B.  Without  a  guide,  512 
Ferineal  incision  for  exploration  of 

the  bladder,  513 

Exstrophy  of  the  bladder,  514 

Catheterization,  516 

Puncture  of  the  bladder,  518 

Above  the  pubes,  518 

Litholapaxy,  518 

Lithotomy,"  524 

General  considerations,  524 

Lateral  lithotomy,  527 

Median  lithotomy,  532 

Supra-pubic  lithotomy,  534 

Prostatectomy,  supra-pubic,  538 

Perineal,  538 

Tumors  of  bladder,  539 

Removal  of  seminal  vesicles,  541 


CHAPTER  VIII. 

OPERATIONS  UPON  THE  GENITO-URINARY  ORGANS  OF  THE   FEMALE. 


Catheterization, 

iii  urethrotomy, 
Lithotomy, 

I  retinal  lithotomy. 
Vesico-vagtna]  lithotomy, 

Occlusl or  atresia  vaginae, 

Perineorapby, 

Prolapse  of  the  posterior  wall  of 
the  vagina, 

1st  v.m 

■_M  variety, 

Hegar'e  method, 
Laceration  of  the  perineum  and 

sphincter  ani, 
Veslco-vaginal  fistula, 
Creation  of  a  veslco-vaginal  Bstula, 
Obliteration  of  the  vagina;  kolpol 

Narrowing  of  the  vagina;  elytror- 

rbaphy, 
Po  tenor  elytrorrhapbj  or  oolpor- 

rbaphy  (Hegar), 

Mm  I  in, 

Lacerated  cervix, 


543 
543 

515 
545 
545 
5 16 
547 

549 
549 

552 

558 
559 
565 


Posterior  section  of  the  cervix, 
Operations  on  the  uterus  and  ad- 
nexa, 

Anatomy, 

Ovariotomy, 

( (Bphorectomy, 

Salpingo-oBpnorectomy, 

Tumors    beneath    broad    liga- 
ment, 

For  ectopic  gestation, 

1 1  ysteropexy, 

Shortening    round    Ligaments 
1  Alexander), 

Laparohysterotomy, 

Symphysiotomy, 

Myomectomy, 

Abdominal  hysterectomy, 
Ainputation      of      gravid 

litems, 

Vaginal  hysterectomy, 
imputation  of  cervix, 

Supra-vaginal, 
Removal  of  mucosa  of  cervix, 


573 

574 
574 
576 

57S 


581 
582 
588 

584 
584 
586 
586 

587 

590 
590 
593 

594 


OPERATIVE  SURGERY. 


PART  I. 

THE  ACCESSORIES  OF  AN  OPERATION. 


ANESTHESIA. 

Local  ancesthesia  may  be  obtained  (1)  by  the  action  of 
cold,  or  (2)  by  the  application  of  an  agent  which  exerts 
locally  a  benumbing  effect  upon  the  nerves. 

1.  The  low  temperature  which  produces  local  anaesthesia 
may  be  obtained  by  the  application  to  the  parts  of  a 
freezing  mixture  (ice  aud  salt),  or  by  the  vaporization  of 
ether  or  ethyl  chloride.  The  former  is  applicable  to  larger 
surfaces  than  the  latter.  A  mixture  of  cracked  ice  and  salt 
is  put  in  a  muslin  bag  and  laid  upon  the  part,  and  a  folded 
compress  or  towel  laid  over  it  to  intensify  its  action.  After 
it  has  been  iu  place  two  or  three  minutes  it  should  be 
removed,  the  sensibility  of  the  skin  tested,  and  the  bag 
reapplied  if  the  desired  effect  has  not  been  produced.  When 
chilled  to  insensibility  the  skin  is  white  and  puffy. 

When  ether  is  used  for  local  anaesthesia  it  should  be 
directed  upon  the  parts  in  a  fine  spray,  or  its  rapid  vapor- 
ization should  be  aided  by  fanning  or  blowing  upon  the 
surface.     It  is  inefficient  when  the  skin  is  very  vascular. 

2.  Carbolic  acid  is  an  efficient  and  convenient  means  of 
producing  local  anaesthesia.  A  cloth  thoroughly  wet  with 
a  3  per  cent,  solution  of  the  acid  should  be  kept  upon  the 
skin  for  fifteen  minutes,  aud  then  the  undiluted  acid  ap- 
plied with  a  brush  aloug  the  line  of  the  proposed  incision. 
This  is  applicable  to  the  opening  of  abscesses,  felons,  etc., 
and  to  many  minor  operations. 

2 


14  OPERATIVE  SURGERY. 

Hydvochlorate  of  Cocaine.  The  injection  under  the  skin 
or  into  a  nerve  of  a  few  drops  of  a  2  or  4  per  cent,  solu- 
tion of  the  hydrochlorate  of  cocaine  produces  a  temporary 
local  anaesthesia,  sufficient  to  permit  the  painless  perform- 
ance of  an  operation  involving  only  the  skin  or  the  layers 
immediately  underlying  it.  A  deeper  injection  into  a  nerve 
produces  anaesthesia  of  the  region  supplied  by  it.  As  this 
agent  acts  upon  the  nerve-fibres,  the  injection  should  be 
made  on  the  proximal  side  of  the  region  to  be  operated 
upon,  and  should  be  directed  toward  and  into  that  region. 

General  Anaesthesia.  The  agents  in  common  use  for 
producing  general  anaesthesia  are  (1)  ether,  (2)  chloroform, 
and  (3)  nitrous  oxide. 

The  great  merit  of  ether  is  in  safety.  Chloroform  is 
more  rapid  in  its  action  at  first,  as  usually  given,  at  least 
less  liable  to  cause  vomiting,  less  disagreeable  in  its  after- 
effects, but  it  is  certainly  more  dangerous.  On  account  of 
its  inflammability,  ether  should  be  used  with  caution  at 
night,  and  as  its  vapor  is  heavier  than  air,  the  lights  should 
be  held  above  the  bed.  Nitrous  oxide  is  suitable  only  for 
very  short  operations.  Its  use  to  obtain  anaesthesia  for  any 
length  of  time  is  as  dangerous  as  that  of  chloroform,  per- 
haps more  so. 

Ether  endangers  life  through  suffocation,  which  may  be 
the  result  of  paralysis  of  the  respiratory  muscles,  or  of 
obstruction  of  the  air- passages  by  the  tongue,  or  by  a  for- 
eign body,  such  as  vomited  matter.  Chloroform  kills  by 
exerting  a  special  influence  upon  the  ganglionic  nerve- 
centres  presiding  over  respiration  and  circulation.  Arrest 
of  the  breathing  and  lividity  of  the  surface  give  timely 
notice  of  danger  from  ether.  Chloroform  may  kill  without 
a  moment's  warning. 

If  during  anaesthetization  by  ether  the  respiratory  muscles 
cease  to  act,  artificial  respiration  should  be  kept  up,  and 
stimulants  administered;  but  the  patient  should  be  kept 
quiet,  should  not  be  whipped  or  excited  to  muscular  action. 
The  danger  comes  from  the  weakness  of  his  muscles,  and 
they  must  not  be  called  upon  for  any  extra  exertion.  If, 
as  is  much  more  common,  the  diaphragm  acts,  but  the  air- 
passages  are  obstructed,  and  the  face  becomes  livid,  the 


THE  ACCESSORIES  OF  AN  OPERATION.  15 

obstruction  must  be  removed,  and  the  breathing  will  then 
take  care  of  itself.  If  the  obstruction  is  due  to  the  presence 
of  a  foreign  body  in  the  glottis  or  trachea  (false  teeth,  vom- 
ited matter),  the  shoulders  and  head  must  be  lowered,  and 
the  hips  raised.  It  may  become  necessary  to  resort  to 
tracheotomy.  If  the  obstruction  is  due  to  the  falling  back 
of  the  tongue  in  consequence  of  the  relaxation  of  the  mus- 
cles of  the  pharynx  and  floor  of  the  mouth,  a  stout  piece 
of  wood  should  be  put  between  the  patient's  teeth  and  his 
tongue  drawn  forward.  The  most  prompt  and  efficient 
way  of  doing  this  is  for  the  operator  to  hook  the  terminal 
joint  of  his  forefiuger  behind  the  root  of  the  tongue  and 
draw  it  forward,  or  the  fingers  should  be  pressed  upward 
and  inward  from  below  the  angles  of  the  jaw. 

When  operating  upon  the  mouth  and  nasal  passages, 
hemorrhage  may  interfere  seriously  with  respiration  and 
anesthetization.  By  placing  the  patient  on  his  back,  and 
allowing  his  head  to  hang  down  over  the  end  of  the  operat- 
ing table,  the  blood  will  be  made  to  flow  away  through  the 
nostrils,  and  the  larynx  will  remain  clear. 

During  the  inhalation  of  chloroform,  death  may  occur 
either  suddenly  by  syncope,  or  more  slowly  with  signs  of 
cerebral  congestion  and  arrest  of  hsematosis.  In  the  first 
case  the  heart  stops,  the  patient  becomes  pale,  the  respira- 
tion superficial ;  the  other  usually  happens  after  conscious- 
ness has  returned,  the  face  suddenly  becomes  livid,  the 
patient  loses  consciousness  again,  and  dies  within  half  an 
hour.  In  the  first  variety,  death  can  generally  be  averted 
by  lowering  the  head,  slapping  the  breast  and  face  with  wet 
towels,  and  applying  the  galvanic  or  faradic  current.  When 
the  galvanic  current  is  used,  the  negative  pole  may  be  placed 
in  the  mouth,  and  the  positive  pole  at  the  anus.  The  faradic 
current  should  be  applied  only  over  the  chest ;  its  applica- 
tion to  the  phrenic  or  pneumogastric  nerves  iu  the  neck  is 
dangerous.  In  the  second  variety  death  is  apparently  inev- 
itable. 

By  the  inhalation  of  nitrite  of  amyl  impendiug  death  may 
sometimes  be  averted. 

Administration  of  the  Ancesthetic.  Chloroform  should  be 
given  upon  a  compress  folded  twice  longitudinally  and  once 


1 6  OPERA TIVE  SUB GEB Y. 

transversely,  so  as  to  be  about  six  inches  square.  The  upper 
fold  is  then  thrown  back,  a  drachm  of  chloroform  poured 
upon  the  lower  one,  and  the  upper  one  replaced  to  prevent 
evaporation  from  that  side.  The  compress  is  then  held 
before  the  mouth  and  nostrils  of  the  patient,  and  whenever 
necessary  the  upper  fold  is  thrown  back,  and  additional 
chloroform  poured  upon  the  lower  one.  No  special  instru- 
ment is  needed  to  prevent  the  administration  of  too  much  at 
a  time.  It  has  been  demonstrated  that  the  amount  of  the 
vapor  of  chloroform  in  the  air  never  exceeds  4|-  per  cent. 

To  give  ether  successfully  three  points  must  be  provided 
for  :  the  evaporating  surface  must  be  large,  the  air  inspired 
by  the  patient  must  pass  across  it,  the  supply  of  ether  must 
be  abundant  so  as  not  to  require  frequent  renewal.  The 
ordinary  cone,  with  certain  modifications,  meets  these  wants 
very  well.  Three  or  four  thicknesses  of  stout  brown  paper, 
or  ten  of  newspaper,  measuring  twelve  by  fifteen  inches, 
should  be  covered  with  a  thick  towel  well  pinned  on,  and 
rolled  into  the  form  of  a  cone,  a  foot  long  and  five  inches  in 
diameter,  and  fastened  with  long  pins.  A  hole  should  be 
left  at  the  apex  of  the  cone  large  enough  to  admit  the  little 
finger,  and  the  corners  at  the  base  should  be  turned  back. 
If  the  towel  is  thick  it  will  hold  all  the  ether  that  is  needed, 
and  if  the  base  is  pressed  closely  against  the  chin,  cheeks, 
and  nose,  all  the  air  breathed  by  the  patient  will  have  to 
enter  by  the  hole  left  at  the  apex,  and  pass  across  the  large 
evaporating  surface  of  the  inside  of  the  cone.  If  the  cone 
is  held  at  first  at  a  short  distance  from  the  mouth  and  then 
brought  gradually  nearer,  complete  anesthesia  may  often 
be  obtained  in  two  or  three  minutes  without  having  caused 
any  strangling,  or  provoked  any  resistance. 

Rectal  Etherization.  It  was  shown  by  Molliere,  in  1884, 
that  general  anesthesia  could  be  readily  obtained  by  the  ad- 
ministration of  ether  by  the  rectum.  The  method  was  at 
once  widely  tried,  but  has  been  abandoned,  except  in  special 
cases,  for  it  was  found  to  be  more  dangerous  than  the  method 
by  inhalation.  The  dangers  are  that  the  anesthetization 
may  unwittingly  be  made  too  profound  and  prolonged,  and 
that  the  contact  of  the  ether  with  the  intestinal  mucous 
membrane  may  cause  a  bloody  diarrhoea. 


THE  ACCESSORIES  OF  AN  OPERATION. 


17 


The  ether  is  placed  in  a  bottle  provided  with  a  tightly- 
fitting  cork  through  which  passes  a  rubber  tube.  The  free 
end  of  the  tube  is  iuserted  in  the  rectum,  and  the  bottle 
placed  in  warm  water. 

The  precautious  to  be  observed  are  that  the  water  should 
not  be  warmer  than  100°  Fahr.,  and  that  as  soon  as  anes- 
thesia is  obtained  the  tube  should  be  withdrawn  from  the 
rectum,  to  be  reapplied  if  necessary.  The  tube  should  be 
large,  and  should  extend  downward  from  the  anus  to  the 
bottle  without  loops  or  coils  in  which  the  ether  might  con- 
dense. 


ARREST   OF   HEMORRHAGE. 


Hemorrhage  is  arrested  :  (1)  by  ligature  ;  (2)  by  torsion  ; 
(3)  by  pressure ;  (4)  by  cold  or  heat ;  (5)  by  position. 


Fig.  1. 


Artery  forceps. 
Fig.  2. 


Self-holdiug  hsernostatic  forceps. 


Ligature. 
ceps  (Figs.  1, 


The  vessel  or  bleeding  point  is  seized  by  for- 
2,  and  3)  with  as   little  of  the  surrounding 


18 


OPERATIVE  SURGERY. 


tissue  as  possible.  It  is  encircled  by  silk  or  catgut,  which  is 
tied  in  a  square  knot  (Fig.  4).  The  portion  distal  to  the 
ligature  should  be  as  small  as  possible. 


Fig.  3. 


Self-holding  haemostatic  forceps  ;   curved. 
Fig.  4. 


Effects  of  torsion  upon  the  coats  of  an  artery. 

Torsion.     Tlie  vessel  is  isolated,  grasped  by  the  forceps, 
drawn  out,  and  twisted  till  it  parts.     Tt  is  not  in  general 

use  except  for  small  vessels.     (Fig-  5.) 


THE  ACCESSORIES  OF  AN  OPERATION. 


19 


Pressure  made  by  sponges,  gauze  pads,  or  clamps  left  in 
place  for  a  few  minutes  will  frequently  be  found  sufficient 
to  arrest  oozing,  venous  hemorrhage,  or  the  bleeding  from 
small  arteries. 

Cold  or  Heat.  Hemorrhage  may  be  checked  by  the 
actual  cautery  at  a  dull-red  heat;  by  ice-cold  water;  or  by 
water  at  a  temperature  of  110°  to  120°  F. 

Position,  either  alone  or  combined  with  pressure,  is  a  val- 
uable haemostatic.  Elevation  of  a  limb  will  diminish  the 
blood  pressure,  and  often  allow  a  coagulum  to  form  in 
some  divided  vessel  where  it  would  otherwise  be  washed 
away  by  the  force  of  the  blood  flow. 

Fig.  6. 


ARTIFICIAL    ISCHEMIA. 


Loss  of  blood  during  an  operation  upon  a  limb  may  be 
prevented  by  pressure  upon  the  main  artery  on  the  proxi- 


20 


OPERATIVE  SVBGEBYr. 


mal  side  of  the  incision.     This  pressure  may  be  made  with 
the  finger,  tourniquet,  or  elastic  cord. 

The  tourniquet  (Fig.  6)  is  composed  of  a  pad,  band,  and 
screw  ;  by  turning  the  screw  the  band  may  be  tightened  at 
will.  The  principle  of  its  application  is  the  compression  of* 
the  artery  against  the  underlying  bone.  A  point  should 
be  selected  in  the  course  of  the  artery  where  such  com- 
pression can  be  made  ;  a  roller  bandage,  an  inch  in  diameter, 
placed  over  the  vessel,  and  parallel  to  its  course,  the  tourni- 
quet then  applied  as  shown  in  Figs.  7  and  8,  and  the  screw 


Fig. 


Fig.  8. 


Mode  of  application  of  tourniquet. 

tightened.  Some  surgeons  prefer  to  place  the  pad  of  the 
tourniquet  upon  the  roller  bandage  itself,  and  not  on  oue 
side  as  shown  in  the  figure.  The  buckle  on  the  band  should 
always  be  much  further  from  the  roller  than  is  represented 
in  the  figures. 

The  elastic  tourniquet  is  applied  by  holding  the  limb  for 
a  short  time  in  an  elevated  position  to  diminish  the  amount 


THE  ACCESSORIES  OF  AN  OPERATION. 


21 


of  blood  in  it.  Then,  without  changing  the  position,  a  soft 
but  stout  rubber  cord  or  band  is  wrapped  several  times 
about  the  limb  sufficiently  tight  to  occlude  all  the  vessels, 
aud  fastened  in  position  by  a  single  knot.  It  should  be 
applied  at  a  convenient  point,  well  above  the  seat  of  opera- 
tion. Or  the  Esmarch  rubber  bandage,  usually  two  or  more 
inches  broad,  is  applied  from  the  fingers  or  toes  of  an  ex- 
tremity spirally  upward,  each  upper  turn  overlapping  the 
one  below  from  a  quarter  to  half  an  inch.  It  is  wound 
tightly  enough  to  completely  empty  all  the  vessels  of  blood 
as  it  advances,  and  is  carried  to  the  point  where  the  rubber 
tourniquet  can  be  best  applied,  which  is  then  done  as 
already  described.     The  spiral  bandage  is  then  removed. 

The  objections  to  the  rubber  bandage  and  tourniquet  are 
the  possibility  of  pressure  paralysis  and  the  certainty  of 
temporary  vasomotor  paralysis,  with  its  consequent  trouble- 
some oozing.  The  advantages  are  that  an  operation  can  be 
performed  upon  the  living  body  with  as  much  ease  and 
certainty  as  upon  the  cadaver.  It  is  very  useful  whenever 
careful  dissection  is  necessary. 

Digital  compression  of  the  main  artery  of  a  part  at  a 
distance  from  the  seat  of  operation  is  a  useful  temporary 
haemostatic.  Amputations  below  the  hip  or  shoulder  can 
be  satisfactorily  performed  by  compression  of  the  femoral 
artery  against  the  os  pubis  or  the  brachial  against  the 
humerus. 

SUTUKES. 

The  interrupted  suture  is  one  in  which  each  stitch  is  tied 
as  it  is  made,  and  the  knot  drawn  to  one  side  of  the  inci- 

FlG.  9. 


sion.      In    Halstead's   subcuticular   method   (Fig.    9)  the 
needle  is  introduced  on  the  under  surface  of  the  skin  on 

2* 


22 


OPERATIVE  SURGERY. 


one  side,  and  brought  out  just  beneath  the  cut  edge,  then 
entered  in  the  reverse  direction  below  the  epidermic  surface 
opposite ;  when  knotted  it  will  lie  wholly  out  of  sight. 

The  object  is  to  avoid  infection  by  the  skin  coccus 
(staphylococcus  epidermidis  albus).  Fine  silk  must  be 
used,  aud  after  a  couple  of  weeks  a  small  pimple  will  form 
over  each  stitch,  and  it  will  be  quietly  thrown  off. 

The  continuous  suture  (Fig.  10)  is  passed  in  the  same 
manner  as  the  interrupted,  but  the  stitches  are  not  cut 
apart  and  tied.     It  is  conveniently  fastened  at  the  last  by 

Fig  10. 


Continuous  suture. 


drawing  it  double  through  the  last  puncture  and  using  the 
free  end  to  make  a  knot  with  the  double  part  attached  to 
the  needle.  The  needle  each  time,  after  emerging  from  the 
skin,  may  be  looped  under  the  immediately  preceding  and 
exposed  portion  of  the  suture  (Fig.  11).  This  makes  it 
resemble  the  interrupted  suture  in  action. 


Fig.  11. 


Continuous  suture. 


The  twisted  or  figure-qf-8  suture  (Fig.  12)  is  made  by 
transfixing  the  lips  of  the  incision  with  a  pin  (Figs.  13  and 
14),  about  the  two  ends  of  which  a  thread  is  then  twisted 
(Fig.  12). 


THE  ACCESSORIES  OF  AN  OPERATION.  23 

Fig.  12. 


Twisted  suture. 
Fig.  13. 

e 


Harelip  pin. 
Fig.  14. 


€S 


Harelip  pin  with  movable  point. 


Tension  or  relaxation  suture  is  the  name  given  to  one 
employed  to  relieve  strain  on  the  sutures  approximating 
the  edges  of  the  wound  The  points  of  entry  and  emer- 
gence should  be  at  a  considerable  distance  from  the  incision. 
The  thread  is  passed  double,  and  in  order  to  lessen  the  ten- 
sion at  any  one  point  its  extremities  are  tied  over  buttons 
or  plates  of  lead  or  pads  of  gauze. 


PREPARATION   OF   MATERIALS    USED   IN   AN   OPERATION. 

Catgut  ranges  from  the  smallest  size,  No.  1,  up  to  No.  6. 
It  is  first  soaked  in  ether  for  twenty-four  hours  to  free  it 
from  fat,  then  wound  on  glass  spools  which  have  been 
recently  boiled.  The  hands  which  do  the  winding  must  be 
thoroughly  scrubbed  and  disinfected,  and  during  the  wind- 
ing the  catgut  must  touch  nothing  which  is  not  surgically 
clean.  The  catgut  is  then  boiled  in  alcohol  for  one  hour, 
and  stored  for  use  in  boiled  absolute  alcohol  in  a  sterilized 
glass  vessel.  The  spools  of  catgut  are  sometimes  soaked 
for  twenty-four  hours  in  a  1  :  1000  aqueous  solution  of 
bichloride  of  mercury  before  boiling. 


24  OPERATIVE  SURGERY. 

Chromicized  catgut  is  made  by  soaking  for  twenty-four 
to  forty-eight  hours  200  parts  of  catgut  by  weight  in  a 
mixture  of  carbolic  acid,  200  parts,  boiled  water  2000  parts, 
and  chromic  acid  1  part.  It  is  then  boiled  in  alcohol  and 
stored  in  boiled  absolute  alcohol. 

Silk  is  used  in  sizes  from  the  smallest,  No.  1,  to  No.  18, 
the  sizes  most  convenient  for  average  use  ranging  from  7 
to  10 — No.  18  is  suitable  for  large  pedicles.  It  is  wound 
on  sterilized  spools,  boiled  in  water  for  half  an  hour,  and 
stored  in  boiled  absolute  alcohol  in  a  sterilized  glass  vessel. 

Silkworm-gut  is  simply  boiled  in  alcohol  for  one  hour, 
aud  stored  in  boiled  absolute  alcohol  in  a  sterilized  glass 
vessel. 

Sponges.  Ordinary  sponges  are  prepared  as  follows : 
Decalcify  in  a  solution  of  one  volume  of  commercial  hydro- 
chloric acid  and  three  volumes  of  water.  Examine  each 
sponge  separately  for  pieces  of  stone  or  coral,  which  must 
be  cut  or  torn  out.  Then  wash  in  running  water  to  re- 
move every  particle  of  sand.  Place  them  in  a  solution  of 
permanganate  of  potassium  of  a  strength  of  about  1  to  16 
of  water  till  they  are  stained  a  chestnut  brown.  Wash 
again  in  running  water  to  remove  the  excess  of  permanga- 
nate. Place  them  in  a  solution  of  hyposulphite  of  soda 
and  oxalic  acid — about  5j  of  each  to  a  pint  of  water,  and 
stir  the  sponges  till  they  are  bleached.  Then  wash  in  run- 
ning water  to  free  from  acid  and  precipitated  sulphur, 
liinse  out  in  a  solution  of  sodium  bicarbonate — about  1 
part  to  25  of  water.  This  neutralizes  any  acid  and  renders 
the  sponge  texture  more  absorbent.  Wash  again  in  steril- 
ized water  and  store  in  a  1  :  20  carbolic  solution. 

Simple  pads  of  sterilized  absorbent  gauze,  with  the  mar- 
gins loosely  hemmed,  make  excellent  and  cheap  sponges ; 
they  should  be  sterilized  by  steam  for  half  an  hour  imme- 
diately before  use. 

Absorbent  gauze  is  best  purchased  from  the  manufacturers. 

It  should  be  cut  into  convenient  lengths  and  sterilized   by 
steara  for  half  an  hour  immediately  before  use. 


THE  ACCESSORIES  OF  AN  OPERATION.  25 

Bichloride  gauze  is  conveniently  made  by  wringing  out 
the  sterilized  absorbent  gauze  in  a  solution  of  bichloride  of 
mercury  1  part,  common  salt  1  part,  and  water  1000  parts. 
The  salt  prevents  the  bichloride  from  changing  to  calomel. 
It  can  then  be  sterilized  by  steam  and  kept  in  a  sterilized 
tight  vessel. 

Iodoform  Gauze.  Where  the  exact  proportion  of  iodo- 
form is  unimportant  it  can  be  made  as  follows  :  Sterilize  a 
strip  of  absorbent  gauze  and  the  hands  of  the  maker.  Dis- 
solve about  5ij  of  castile  soap  in  §j  of  a  1  :  20  aqueous  car- 
bolic solution.  Strain  this  through  a  piece  of  sterilized 
gauze  to  render  the  suds  clear,  and  boil  the  filtrate.  Mix 
this  filtrate  with  nearly  an  equal  part  of  iodoform  in  a 
sterilized  basin.  Again  sterilize  the  hands  and  wring  out 
the  strip  of  sterilized  gauze  in  this  mixture.  Store  in  a 
sterilized  tightly-covered  vessel  in  the  dark. 

lodojorm  gauze  containing  10  per  cent  of  iodoform. 

Ordinary  absorbent  gauze  averages  about  an  ounce  in 
weight  to  the  yard,  and  ten  ounces  of  gauze  will  absorb 
about  sixteen  ouuces  of  water.  After  sterilizing  the  hands, 
wring  out  nine  yards  of  sterilized  absorbeut  gauze  in  a 
mixture  of  sixteen  ounces  of  boiled  soapsuds  with  one 
ounce  of  iodoform,  and  store  in  the  dark  in  an  air-tight 
sterilized  vessel. 

The  iodoform  mixture  cannot  be  boiled  without  decom- 
posing the  iodoform.  The  soapsuds  cause  the  iodoform  to 
mechanically  adhere  to  the  gauze.  It  is  understood  that 
the  basin  in  which  the  mixing  of  the  gauze,  soapsuds,  and 
iodoform  is  carried  out  has  been  cleaned  and  sterilized 
immediately  previous  to  the  process. 

Some  prefer  to  sterilize  the  prepared  gauze  by  steam ; 
but  this  sometimes  decomposes  part  of  the  iodoform,  and 
the  iodine  thus  liberated  is  very  irritating  to  the  skin. 

Drainage  tubes  are  most  conveniently  made  of  ordinary 
rubber  tubing — the  red  is  the  best — or  of  glass.  These 
should  be  boiled  and  stored  in  boiled  alcohol  or  1  :  1000 
bichloride  solution,  and  immediately  before  use  boiled 
again. 


26  OPERATIVE  SURGERY. 

Absorbable  bone  drainage  tubes  are  sometimes  used. 
They  can  be  obtained  from  the  instrument  makers. 

Absorbent  cotton  is  best  purchased  of  the  manufacturers. 
This  and  plain  cotton  can  be  sterilized  by  dry  heat  in  an 
oven  at  300°  F.  maintained  for  half  an  hour. 

Rubber  tissue  is  prepared  by  washing  thoroughly  in  a 
1  :  20  aqueous  carbolic  solution  and  soap.  It  is  then 
washed  in  alcohol  and  stored  in  1  :  1000  bichloride  of  mer- 
cury solution. 

STERILIZATION. 

The  Arnold  steam  sterilizer  is  most  efficient  for  general 
sterilization,  although  instruments  are  very  apt  to  rust 
when  subjected  to  this  method  of  disinfection,  in  which 
steam  is  the  sole  agent.  It  is  so  constructed  that  the  steam 
is  condensed  after  it  is  used,  and  the  water  needs  only  infre- 
quent renewal.  Instruments  must  be  treated  in  the  Arnold 
sterilizer  for  about  fifteen  minutes,  and  other  appliances  and 
accessories  (gowns,  dressings,  etc.)  for  from  half  an  hour  to 
three  hours,  according  to  the  compactness  of  the  bundle. 

A  very  serviceable  sterilizer  can  be  made  from  an  ordi- 
nary asparagus  cooker — a  covered  tin  vessel  about  twice  as 
long  as  it  is  wide  and  deep — furnished  with  a  removable 
tray.  Instruments  must  be  cleaned  and  then  boiled  for  at 
least  ten  minutes  after  use,  and  again  boiled  immediately 
before  another  use  in  a  1  per  cent,  solution  of  sodium  car- 
bonate. The  latter  is  a  powerful  disinfectant  in  boiling 
water,  and,  furthermore,  helps  to  prevent  rusting.  After 
the  instruments  have  been  treated  in  the  steam  sterilizer  or 
boiling  water  they  should  be  placed  in  a  tray  containing  a 
sterilized  1  :  40  carbolic  solution,  or  in  plain  boiled  and 
cooled  water.  Some  surgeons  prefer  to  wipe  each  instru- 
ment separately,  after  boiling,  with  a  piece  of  sterilized  cot- 
ton moistened  with  a  3  per  cent,  solution  of  carbolic  acid. 

Articles  such  as  roller  bandages  or  gauze  tightly  packed 
in  some  vessel  for  transportation  or  storage  cannot  be  ren- 
dered perfectly  sterile  throughout  unless  subjected  to  the 
action  of  steam  under  pressure;  for  at  least  half  an  hour.    A 


HIE  ACCESSORIES  OF  AN  OPERATION.  27 

somewhat  expensive  apparatus  designed  to  meet  this  re- 
quirement is  manufactured  by  the  Sprague-Schuyler  Com- 
pany, of  this  city. 


THE    WOUND     MADE    BY    THE    SUEGEON    AND     ITS 
TREATMENT. 

The  secret  of  success  in  operative  surgery  lies  in  abso- 
lute cleanliness  of  the  operator  and  his  assistants,  the  wound 
and  its  surrounding  parts,  of  all  instruments,  dressings,  and 
accessories,  and  of  the  room  and  its  contents. 

On  the  morning  of  the  day  before  the  operation  the  skin 
should  be  washed  and  scrubbed  with  green  soap,  shaved  if 
necessary,  and  sponged  off  with  a  1  :  1000  solution  of  bichlo- 
ride of  mercury.  It  is  then  spread  with  a  layer  of  green  soap, 
and  covered  with  compresses  saturated  in  the  same  material. 
Over  this  is  placed  a  piece  of  rubber  tissue  to  prevent  dry- 
ing, and  the  "  soap  poultice  "  is  left  in  place  till  the  even- 
ing before  the  operation,  or  for  about  twelve  hours.  It  is 
then  removed,  and  the  area  washed  carefully  with  a  1  :  1000 
bichloride  solution,  aud  a  wet  1  :  5000  bichloride  dressing 
applied  and  not  removed  till  the  patient  is  on  the  table — 
at  least  twelve  hours  later.  The  surface  is  then  washed 
with  ether,  and  again  with  the  1  :  1000  bichloride  solution. 
The  surgeon,  his  assistants,  and  any  attendants  in  the  oper- 
ating-room should  have  their  arms  bare  to  the  elbow, 
and  wear  sterilized  gowns  reaching  to  the  feet.  All  these 
persons  must  thoroughly  scrub  with  a  sterilized  brush, 
green  soap,  and  hot  water  their  arms,  hands,  aud  finger- 
nails. Then  clean  the  finger-nails  with  a  clean  instrument 
and  again  scrub  them.  Rinse  the  hands  and  arms  thor- 
oughly in  alcohol  and  soak  them  five  minutes  by  the  watch 
in  a  1  :  1000  bichloride  of  mercury  solution.  If  anything 
not  previously  sterilized  is  touched  by  auy  one  in  the  course 
of  the  operation,  the  cleansing  process  must  be  repeated  by 
that  person. 

The  incision  should  be  clean  and  smooth,  and  large 
enough  to  give  plenty  of  room  and  permit  easy  recognition 
of  all  the  parts  as  they  are  reached.  If  the  operator 
attempt  to  work  through  too  small  an  opening  his  manipti- 


28  OPERATIVE  SURGERY. 

latioDS  and  efforts  at  retraction  and  clamping  are  liable  to 
cause  bruising  of  the  margins  of  the  wound.  There  must 
be  no  unnecessary  or  jagged  cuts,  which  leave  pedunculated 
masses  of  tissue  to  necrose.  In  order  to  minimize  the 
amount  of  foreign  material  the  ligatures  should  be  as  few 
and  small  as  possible.  Much  of  the  hemorrhage  can  be 
stopped  by  simple  pressure,  as  by  clamps  left  in  place  for  a 
few  moments,  or  by  packing  with  sponges  or  pads  of  gauze. 
Strong  antiseptics  and  rough  handliug  in  a  perfectly  clean 
wound  are  to  be  avoided.  After  all  bleeding  has  been 
checked,  every  portion  of  the  wound  surface  should  be 
brought  into  contact  with  some  other,  and  held  there  im- 
movably for  from  five  to  ten  days.  A  well-applied  dress- 
ing, aided  by  a  few  sutures,  will  generally  be  found  sufficient 
for  this  purpose.  Buried  sutures  should  be  used  with  cau- 
tion. They  unfavorably  modify  the  nutrition  of  the  parts, 
and  thereby  conduce  to  the  development  of  such  septic 
germs  as  may  be  present. 

The  question  of  drainage  depends  upon  a  number  of  con- 
siderations. A  large  effusion  of  blood  or  serum  may  be 
expected  to  follow  some  operations,  and,  by  separating  the 
apposed  surfaces  of  the  wound,  prevent  primary  union.  A 
well-applied  dressing  and  sutures  sufficiently  far  apart — 
half  an  inch  to  an  inch — to  allow  the  effusion  to  escape 
between  them  will  generally  suffice.  This  may  be  supple- 
mented by  a  flat  strip  of  sterilized  rubber  tissue  introduced 
into  the  depths  of  the  wound  and  brought  out  between  the 
sutures.  If  spaces  exist  which  cannot  be  obliterated,  heal- 
ing by  the  so-called  organization  of  a  blood-clot  can  be 
attempted;  or  drainage  may  be  practised  as  if  infection 
were  expected. 

If  it  is  thought  necessary  to  use  a  drainage  tube  in  an 
aseptic  wound  which  remains  so,  the  tube  should  be  re- 
moval with  every  antiseptic  precaution  at  the  end  of  twenty- 
four  to  thirty-six  hours.  Pre-existing  suppuration  in  the 
wound  or  its  vicinity  always  calls  for  drainage.  If  suppu- 
ration occurs  in  a  previously  aseptic  wound,  every  facility 
must  be  given  for  the  escape  of  pus  at  the  earliest  moment. 
The  whole  wound  may  need  to  be  laid  wide  open  and  packed 
with  gauze.  Pockets  and  dependent  angles  must  be  con- 
sidered and  counter-openings  made  if  necessary. 


THE  ACCESSORIES  OF  AN  OPERATION.  29 

An  aseptic  wound  is  closed  by  any  suitable  one  of  the 
different  kinds  of  suture  and  covered  with  a  strip  of  steril- 
ized rubber  tissue,  over  which  is  placed  a  layer  of  iodoform 
gauze,  or  the  rubber  tissue  may  be  omitted.  Apply  next 
to  the  iodoform  gauze  compresses  of  sterilized  absorbent 
gauze,  dry,  or  wet  in  a  1  :  5000  solution  of  bichloride  of 
mercury;  cover  these  with  sterilized  absorbeut  cotton,  which 
acts  as  a  filter  against  germs  coming  from  without,  and  also 
absorbs  leakage  from  the  wound.  Bandage  tightly  enough 
to  cause  an  even  pressure  and  immobilization,  and  yet  not 
interfere  with  circulation. 


PART  II. 

LIGATURE   OF   THE   ARTERIES. 


GENERAL    DIRECTIONS. 


A  point  for  the  application  of  the  ligature  should  be 
chosen,  if  possible,  not  nearer  than  half  an  inch  to  airy  col- 
lateral branch  above  or  below  it.     The  operator  should 


Fig.  15. 


This  diagram  represents  three  distinct  operations. 

A.  Opening  the  sheath.    B.  Drawing  ligature  round  the  artery. 

C.  Tying  artery. 

make  himself  thoroughly  familiar  with  the  anatomical  rela- 
tions of  the  parts  and  the  landmarks  of  the  operation;  he 
should   proceed   methodically,  in  accordance  with  a  definite 


LIGATURE  OF  THE  ARTERIES.  31 

plan,  and  seek  for  and  recognize  each  layer,  each  landmark 
in  its  order. 

It  is  well  to  mark  upon  the  skin  with  ink  or  iodine  the 
line  of  the  proposed  incision ;  the  incision  should  be  free, 
and,  so  far  as  possible,  its  centre  should  correspond  with 
the  point  at  which  the  ligature  is  to  be  applied.  The  first 
incision  should  go  fairly  through  the  skin,  and  then  be  car- 
ried down  to  the  enveloping  fascia  by  repeated  applications 
of  the  knife.  The  fascia  should  be  pinched  up,  nicked,  and 
divided  upon  a  director  if  the  vessels  lie  immediately  below 
it,  or  upon  the  finger  if  a  muscular  interstice  is  to  be  sought 
for.  The  division  of  the  fascia  should  equal  in  length  the 
external  incision. 

The  knife  is  then  laid  aside  and  the  artery  sought  for  by 
separating  the  tissues  with  the  fingers  or  a  director.  The 
sheath  is  recognized  by  the  communicated  pulsation,  and 
by  the  absence  of  the  pinkish-white  color  and  smooth  shin- 
ing surface  which  characterize  the  artery.  When  found,  it 
is  gently  pinched  up  with  the  forceps,  the  flat  of  the  knife 
laid  upon  it,  and  a  hole  one-quarter  of  an  inch  long  care- 
fully made  in  it.  A  distinct  sheath  is  found  only  about 
the  main  trunks,  and  is  replaced  in  the  others  by  a  layer  of 
cellular  tissue,  which  is  more  readily  separated  by  tearing 
with  the  point  of  a  director  or  with  two  forceps. 

When  the  pinkish-white  coat  of  the  vessel  has  been  fairly 
exposed,  each  edge  of  the  hole  in  the  sheath  is  grasped  in 
turn  with  forceps,  and  the  sides  of  the  vessel  gently  sepa- 
rated from  the  sheath  by  tearing  through  the  slight  attach- 
ments with  the  point  of  a  director. 

Pig.  16. 


Aneurism  needle. 


A  threaded  aneurism  needle  is  then  entered  on  that  side 
where  the  parts  lie  that  are  most  to  be  avoided,  and  passed 
behind  the  artery,  care  being  taken  not  to  raise  the  latter 
from  its  bed,  until  its  eye  appears  upon  the  other  side ;  the 
thread  is  then  picked  up  with  forceps  and  drawn  through 
while  the  needle  is  withdrawn.    The  precaution  should  never 


32 


OPERATIVE  SURGERY. 


be  omitted  of  trying  if  compression  of  the  vessel  between 
the  finger  and  the  ligature  arrests  pulsation  in  its  distal 
branches,  for  the  best  surgeons  have  mistaken  a  nerve  or  strip 
of  fascia  for  the  artery.  The  main  trunks  can  be  readily 
distinguished  from  the  veins  by  their  appearance — the  veins 
resembling  a  leech,  while  the  arteries  are  white  and  feel 
like  a  cord  or  band  under  the  finger — and  by  their  known 
anatomical  relations  ;  but  it  is  often  very  difficult  to  recog- 
nize the  smaller  arteries,  since  they  closely  resemble  the 
veins.  The  operator  has  to  depend  upon  three  indications  : 
(1)  the  fact  that  when  there  are  two  satellite  veins  the  artery 
is  placed  between  them  ;  (2)  pulsation  ;  (3)  alternate  com- 
pression of  the  vascular  bundle  at  the  two  ends  of  the  inci- 
sion. Pressure  at  the  proximal  end  causes  the  artery  to 
shrink  and  the  veins  to  swell ;  pressure  at  the  distal  end 
has  the  contrary  effect. 

Fig.  17. 


a  a.  Inner  coat  of  an  artery  ruptured  by  a  ligature. 


The  ligature  is  then  tied  with  a  square  knot  (Fig.  4), 
tightly  enough  to  cut  the  inner  coats  of  the  vessel,  and  one 
or  both  (;nds  cut  short,  according  to  the  material  used. 
Aseptic  catgut  or  silk  should  be  used,  both  ends  cut  short, 
and   the  wound  closed.     The  lymph   thrown   about  these 


LIGATURE  OF  THE  ARTERIES.  33 

ligatures  gives  strength  to  the  wall  of  the  vessel  and  addi- 
tional security  against  secondary  hemorrhage.  Primary 
union,  at  least  of  the  deep  parts  of  the  wound,  may  be  con- 
fidently expected. 

While  making  the  incisions  the  position  of  the  parts 
should  be  such  that  the  muscles  which  serve  as  guides  shall 
be  tense,  but  while  seeking  for  the  artery  the  muscles  should 
be  relaxed  so  as  to  give  more  room. 


ANATOMY   OP   THE   SUPRA-CLAVICULAR   REGION. 

The  superficial  fascia  underlies  the  platysma,  and  incloses 
the  sterno-cleido-mastoid  in  a  reduplication  of  itself.  The 
middle,  or  sterno-clavicular,  fascia  has  a  common  origin 
with  the  superficial  fascia  in  the  linea  alba  between  the  two 
sterno-thyroid  muscles,  divides  into  three  layers  to  form 
sheaths  for  the  sterno-thyroid  and  sterno-hyoid,  unites,  and 
again  divides  to  form  a  sheath  for  the  omo-hyoid,  unites 
again  and  finally  joins  the  superficial  fascia  between  the 
trapezius  and  sterno-cleido-mastoid.  This  middle  fascia  is 
strong  and  resisting,  and  incloses  all  the  vessels  of  the 
region  except  the  external  jugular  vein,  which  is  subcuta- 
neous throughout  its  course  until  it  turns  inward  to  join  the 
subclavian  above  the  clavicle.  These  two  fascia?  are  sepa- 
rated from  each  other  and  from  the  skin  by  loose  cellular 
tissue,  in  which  a  large  amount  of  fat  may  be  deposited, 
and  it  is  of  prime  importance  therefore  that  they  should  be 
recognized  in  the  search  for  the  vessels. 

The  vessels  which  are  approached  through  this  region  are 
the  innominate,  the  subclavian,  and  the  common  carotid. 
The  bifurcation  of  the  innominate  corresponds  with  the 
sterno-clavicular  articulation,  and  in  old  people,  as  well  as 
in  exceptional  cases,  rises  from  five  to  ten  millimetres  above 
it.  It  lies  in  front  and  on  the  right  side  of  the  trachea, 
and  is  crossed  anteriorly  by  the  left  innominate  vein.  At 
the  bifurcation  the  subclavian  lies  behind  and  to  the  outer 
side  of  the  carotid,  and  is  crossed  by  the  pneumogastric  and 
phrenic  nerves  close  to  its  origin,  the  former  giving  off  the 
recurrent  laryngeal,  which  turns  under  the  artery  and  rises 
again  behind  it.    The  carotid,  which  at  first  lies  behind  the. 


34  OPERATIVE  SURGERY. 

sternocleidomastoid,  soon  reaches  its  anterior  edge,  and 
at  the  same  time  increases  its  distance  from  the  trachea. 
While  the  internal  jugular  lies  wholly  within  the  middle 
cervical  fascia,  the  subclavian  vein  is  enveloped  by  a  redu- 
plication of  it  and  held  closely  against  the  clavicle  thereby. 
It  is  therefore  more  superficial,  and  on  a  lower  plane  than 
the  curved  portion  of  the  subclavian  artery,  and  need  not 
be  uncovered  in  the  search  for  the  latter.  The  branches  of 
the  subclavian,  seven  in  number,  arise  (with  one  exceptiou, 
the  transversalis  colli)  from  its  first  portion,  that  comprised 
between  its  origin  and  the  inner  border  of  the  scalenus  an- 
ticus.  The  transversalis  colli  may  arise  from  the  first  part, 
or  the  second  (between  the  scaleni),  or  even  the  third 
(beyond  the  scaleni).  The  supra-scapular  crosses  in  front 
of  the  scalenus  anticus  and  runs  downward  and  outward 
to  the  clavicle,  lying  below  the  line  of  the  incision  made  in 
tying  the  subclavian  in  its  third  portion. 


LIGATURE    OF   THE    INNOMINATE    ARTERY. 

Anatomy.  The  artery  is  in  relation  in  front  with  the 
innominate  veins  and  the  pneumogastric  nerve;  on  the 
inner  side  with  the  trachea ;  on  the  outer  side  and  behind 
with  the  pleura.  It  lies  immediately  behind  the  sterno- 
clavicular articulation. 

Five  different  incisions  have  been  proposed.  A  vertical 
one  in  the  middle  of  the  neck  (King) ;  a  horizontal  one  4| 
inches  long,  beginning  in  the  middle  line  and  passing  out- 
ward parallel  to  and  half  an  inch  above  the  clavicle 
(Manee);  an  oblique  one  in  the  interval  between  the  ster- 
nal and  clavicular  attachments  of  the  sterno-eleido-mastoid 
(Si'dillot) ;  an  oblique  one  from  the  anterior  border  of  the 
left  sterno-eleido-mastoid  21  inches  above  the  clavicle  down 
to  and  a  little  beyond  the  left  sternoclavicular  articulation 
(Velpcau) ;  a  V-shaped  one,  of  which  one  side  lies  over  the 
anterior  edge  of  the  sterno-eleido-mastoid,  and  the  other  is 
parallel  to  and  a  little  above  the  clavicle  (Mott).  The  single 
incisions  do  not  give  sufficient  room,  and  although  they  are 
more  brilliant  they  should  give  way  to  the  more  prudent 
and  practical  one  proposed  by  Mott. 


LIGATURE  OF  THE  ARTERIES.  35 

Operation.  An  incision  3|  inches  in  length  is  carried 
along  the  anterior  edge  of  the  right  sterno-cleido-mastoid, 
ending  half  an  inch  above  the  sternum  (Fig.  18  A).  Another, 
of  the  same  length,  is  carried  outward  from  the  lower  end 
of  the  first,  half  an  inch  above  and  parallel  to  the  right 
clavicle.  These  incisious  are  carried  down  to  the  superficial 
fascia,  and  the  triangular  flap  between  them  dissected  up. 
If  the  anterior  jugular  is  encountered  it  must  be  drawn 
downward.  The  sternal  and  part  of  the  clavicular  attach- 
ments of  the  sterno-cleido-mastoid  are  now  divided  half  an 

Fig.  18. 


/  /  \ 

IE         B 

Ligature  of  Arteries. 

A.  Innominate.  B.  Second  or  third  portion  of  subclavian.  C.  Second  or  third 
portion  of  subclavian  (Skey.)  D.  Vertebral  or  inferior  thyroid.  E.  Axillary 
below  the  clavicle. 

inch  above  the  bone  on  a  director  or  with  forceps  and  knife, 
and  the  muscle  drawn  upward  and  outward,  uucovering 
the  sterno-thyroid  and  sterno-hyoid  and  the  middle  cervical 
fascia,  which  here  is  very  dense  and  covered  by  the  inferior 
thyroid  veins.  The  outer  fibres  of  the  sterno-hyoid  and 
sterno-thyroid  are  now  divided,  the  thyroid  veins  drawn 
aside,  and  the  underlying  or  middle  fascia  torn  through 
with  the  director,  or  opened  very  carefully  with  the  knife. 
The  common  carotid  is  now  seen  at  the  bottom  of  the  wound 
and  traced  downward  to  the  innominate.  The  internal 
jugular  is  carefully  pressed  outward  with  a  retractor ;  the 


36  OPERATIVE  SURGERY. 

left  forefinger,  passed  into  the  wound  between  the  artery 
aud  the  innominate  veins,  presses  the  latter  against  the 
sternum,  and  the  operator  proceeds  carefully  to  clean  the 
artery  with  a  director  half  an  inch  below  its  bifurcation. 
The  needle,  guided  by  the  finger,  is  passed  from  the  outer 
side  so  as  to  avoid  the  vein,  nerve,  and  pleura. 

Bardenheuerx  exposes  the  innominate  by  resection  of  a 
portion  of  the  sternum.  A  transverse  incision  is  made 
along  the  upper  border  of  the  sternum  and  iuner  third  of 
the  clavicle  on  both  sides.  Another  incision  is  made  in  the 
median  line  at  right  angles  to  this  from  the  larynx,  well 
down  upon  the  sternum.  In  the  transverse  incision  the 
sterno  mastoid,  sterno-hyoid,  and  sterno-thyroid  muscles, 
and  the  deep  fascia  are  cut  through.  The  inner  inch  of  the 
left  clavicle  and  first  rib  are  resected  subperiosteally.  By 
working  inward  through  this  gap  the  periosteum  is  freed 
from  the  posterior  surface  of  the  manubrium,  and  this  bone 
is  chiselled  through  transversely  an  inch  below  its  upper 
border,  and  removed  by  cutting  the  right  clavicle  and  first 
and  second  right  ribs  close  to  the  sternal  border.  The  peri- 
osteum is  cut  in  the  median  line,  the  left  innominate  vein 
is  pushed  down  and  the  right  drawn  to  the  right  side,  and 
the  aneurism  needle  passed  from  right  to  left  to  avoid  the 
pleura. 

The  innominate  has  been  tied  only  for  aneurism  of  itself, 
of  the  subclavian,  or  of  the  primitive  carotid;  but  as  it  has 
been  shown2  that  the  treatment  of  aneurism  by  distal  liga- 
ture yields  satisfactory  results,  this  operation  is  seldom 
justifiable.  It  may  be  rendered  necessary  by  hemorrhage 
from  the  subclavian  or  carotid,  but  the  attempt  should 
always  be  made  to  tie  the  injured  vessel  in  the  wound 
before  resorting  to  so  dangerous  a  method  as  ligature  of  the 
innominata. 

LIGATURE   OF   THE   SUBCLAVIAN    ARTERY. 

The  anatomical  difference  between  the  right  and  left  sub- 
clavian is  confined  to  the  first  portion  of  the  artery,  which 

1  Dent.  mc.i.  Wocn..  vol.  n.,  No.  40,  i>.  688. 

-  Prof.  W.  IJ.  Van  Buren,  on  "Aneurism."    Paper  read  before  the  International 
Medical  Congress,  Philadelphia,  1876. 


LIGATURE  OF  THE  ARTERIES.  37 

in  the  left  is  much  longer,  more  vertical  in  its  direction,  and 
situated  more  posteriorly  even  than  the  innominate ;  a 
separate  description  therefore  is  required  only  for  the  first 
portion. 

Operation.  A  V-shaped  incision  similar  to  that  described 
for  ligature  of  the  innominata  (Fig.  18)  is  made  upon  the 
left  side,  and  carried  through  the  sterno-cleido-mastoid  and 
outer  fibres  of  the  sterno-thyroid  and  sterno-hyoid  muscles 
and  the  middle  cervical  fascia  as  before  described.  The 
carotid  is  then  recognized,  and,  together  with  the  internal 
jugular,  drawn  outward  with  a  blunt  hook.  The  muscles 
are  now  relaxed  by  bending  the  head  and  neck  forward, 
and  the  cellular  tissue  torn  through  with  forceps  and  direc- 
tor. The  knife  should  no  longer  be  used,  on  account  of  the 
risk  of  injury  to  the  thoracic  duct,  which  is  imbedded  in  the 
loose  tissue  between  the  vessels  and  the  vertebra?,  and  is 
rendered  very  difficult  of  recognition  by  its  small  size  and 
thin  walls.  It  runs  directly  across  the  route  to  the  artery 
while  passing  from  the  bodies  of  the  vertebrae  to  the  ante- 
rior border  of  the  scalenus  anticus,  and  can  best  be  avoided 
by  making  the  search  below  and  to  the  outer  side  of  it  in 
the  lower  angle  of  the  wound. 

The  finger,  passed  downward  and  backward  behind  the 
carotid,  soon  feels  the  artery  by  pressing  it  against  the  side 
of  the  spinal  column,  the  loose  cellular  tissue  surrounding 
it  is  easily  separated  with  the  director,  the  vessel  cleaned, 
and  the  needle  passed  from  the  inner  side.  The  needle 
should  have  a  short  curve,  and  its  point  should  be  kept 
close  agaiust  the  vessel,  so  as  to  avoid  injuring  the  pleura. 

1st  Portion.  Right  Subclavian.  It  is  exposed  in  the  same 
manner  as  the  innominate  artery,  and  the  ligature  passed 
from  the  outer  side,  the  pneumogastric  and  phrenic  nerves 
being  pressed  inward  toward  the  carotid.  The  great  danger 
of  this  operation  lies  in  the  proximity  of  collateral  branches. 

2d  Portion.  This  operation,  first  proposed  and  performed 
by  Dupuytren,  is  rendered  dangerous  by  the  fact  that  one, 
and  sometimes  several  large  branches  are  given  off  from 
this  part  of  the  artery.  The  preliminary  steps  are  the 
same  as  those  employed  in  ligature  of  the  3d  portion  ;  after 

3 


38  OPERATIVE  SURGERY. 

the  middle  cervical  fascia  has  been  divided,  the  tubercle  of 
the  first  rib  and  the  external  border  of  the  scalenus  anticus 
are  sought,  the  muscle  bared  and  divided  upon  a  director, 
the  phrenic  uerve  which  lies  upon  its  auterior  aspect  being 
carefully  avoided.  As  soon  as  the  muscular  fibres  are  cut 
they  retract  and  leave  the  artery  in  full  view. 

3c?  Portion.  Anatomy.  The  3d  portion  of  the  subclavian 
lies  between  the  outer  border  of  the  scalenus  anticus  and 
the  tubercle  of  the  first  rib  in  front  and  the  brachial  plexus 
behind,  and  below  the  posterior  belly  of  the  omohyoid  ;  it 
is  crossed  on  a  much  more  superficial  plane  by  the  external 
jugular,  which  enters  the  subclavian  near  the  middle  of  the 
clavicle.  In  muscular  subjects  the  clavicular  insertions  of 
the  trapezius  and  sterno-cleido-mastoid  muscles  lie  near  to, 
or  may  even  join,  one  another ;  in  others  they  are  from  two 
to  three  inches  apart.  Ordinarily  the  vessel  lies  at  a  depth 
of  one  or  one  and  a  half  inches  below  the  surface,  but  in 
very  fat  persons,  or  when  the  clavicle  has  been  pushed 
upward  by  an  axillary  aneurism,  this  distance  may  be 
increased  to  three  inches. 

Operation.  Beginning  an  inch  outside  of  the  sterno- 
clavicular articulation,  make  an  incision  three  or  four  inches 
long  parallel  to  and  half  an  inch  above  the  clavicle  (Fig. 
18,  B).  Divide  the  skin  and  the  platysma ;  when  the  ex- 
ternal jugular  is  exposed  draw  it  to  the  inner  side  or  divide 
it  between  two  ligatures.  Divide  on  a  director  the  super- 
ficial fascia,  and  the  clavicular  portion  of  the  mastoid  muscle 
if  necessary,  and  seek  the  posterior  belly  of  the  omohyoid. 
Draw  this  muscle  outward  and  upward,  and  feel  for  the 
tubercle  of  the  first  rib,  following  down  the  outer  border  of 
the  scalenus  anticus.  Depress  the  shoulder  as  much  as  pos- 
sible, denude  the  artery  with  the  finger-nail  or  the  point  of 
a  director,  and  pass  the  needle  from  below,  taking  care  not 
to  include  the  lowest  bundle  of  the  brachial  plexus  in  the 
ligature.  In  order  to  avoid  mistaking  this  bundle  for  the 
artery,  the  tubercle  of  the  first  rib  should  always  be  found  ; 
the  artery  lies  against  it,  between  it  and  the  nerve. 

Skey  prefers,  in  difficult  cases,  a  curved  incision  "com- 
menced about  two  and  a  half  or  three  inches  above  the 
clavicle,  upon,  or  immediately  on  the  outer  edge  of,  the 


LIGATURE  OF  THE  ARTERIES.  39 

mastoid  muscle.  This  incision  is  carried  slightly  outward 
and  downward,  toward  the  acromion,  aud  then  curved  in- 
ward along  the  clavicular  origin  of  the  mastoid  muscle." 
(Fig.  18,  C.)  Ordinarily  the  external  jugular  is  left  to  the 
outer  side  of  the  incision. 


LIGATURE    OF    THE   SUPERIOR   THYROID    ARTERY. 

It  arises  close  to  the  bifurcation  of  the  common  carotid 
at  the  upper  border  of  the  thyroid  cartilage,  and  is  in  rela- 
tion with  the  superior  laryngeal  nerve  on  its  inner  side. 

Operation.  A  two-inch  incision  is  made  along  the  ante- 
rior border  of  the  sterno-mastoid  muscle,  with  its  centre 
opposite  the  upper  border  of  the  thyroid  cartilage.  The 
skin  fascia  aud  platysma  are  divided,  the  sterno-mastoid 
drawn  out,  and  the  carotids  recognized. 

The  superior  thyroid  artery  will  be  found  springing  from 
the  anterior  surface  of  the  external  carotid  close  to  the  bifur- 
cation of  the  common  carotid  artery.  Pass  the  needle  from 
above  down,  avoiding  the  superior  laryngeal  nerve. 


LIGATURE    OF   THE    INFERIOR   THYROID. 

Anatomy.  After  passing  vertically  upward,  the  artery 
curves  inward  to  reach  the  under  surface  of  the  thyroid 
gland.  The  highest  point  of  its  curve  is  half  an  inch 
below  the  prominence  on  the  transverse  process  of  the  sixth 
cervical  vertebra,  named  by  Chassaignac  the  carotid  tubercle. 
In  old  people  it  is  somewhat  higher.  It  lies  behind  the 
common  carotid  and  internal  jugular,  and  is  separated  from 
them  by  more  or  less  dense  cellular  tissue.  The  guides  to 
the  vessel  are  the  carotid  and  Chassaignac's  tubercle. 

Operation.  Make  an  incision  three  and  a  half  or  four 
inches  in  length  along  the  anterior  border  of  the  sterno- 
cleido-mastoid,  ending  an  inch  above  the  clavicle  (Fig. 
18,  D).  Lay  bare  the  border  of  the  muscle,  and  draw  it 
outward,  tear  through  or  divide  the  middle  fascia,  and  draw 
the  carotid  and  internal  jugular  outward  with  a  retractor. 
Flex  the  head  slightly  to  relax  the  parts,  feel  with  the  finger 


40  OPERATIVE  SURGERY. 

for  the  carotid  tubercle,  and  seek  the  artery  below  it,  sepa- 
rating the  cellular  tissue  with  a  director.  Pass  the  ueedle 
between  the  artery  and  vein. 

Drobeck1  makes  an  iucision  along  the  outer  border  of 
the  sterno-mastoid  muscle  from  the  clavicle  to  the  thyroid 
cartilage.  The  omohyoid  muscle  and,  just  below  and  par- 
allel to  it,  the  transversalis  colli  artery  cross  the  wound 
transversely  beneath  the  sterno-mastoid,  and  overlie  the 
phrenic  nerve  as  it  passes  vertically  down  on  the  scalenus 
anticus.  At  the  inner  border  of  the  latter  is  the  ascending 
cervical  artery.  The  sterno-mastoid  and  great  vessels  are 
drawn  toward  the  median  line,  and  either  the  ascending 
cervical  or  transversalis  colli  artery  is  followed  back  to 
the  thyroid  axis.  The  inferior  thyroid  artery  will  be  found 
at  the  inner  side  of  the  ascending  cervical  close  to  the  inner 
border  of  the  scalenus  anticus  just  below  the  carotid  tuber- 
cle. The  recurrent  laryngeal  nerve  lies  still  nearer  the 
median  line,  and  must  not  be  included  in  the  ligature, 
which  should  be  passed  from  within  outward. 


LIGATURE    OF   THE    VERTEBRAL    ARTERY. 

Anatomy.  The  vertebral  artery  passes  from  the  first 
portion  of  the  subclavian  upward  and  backward  to  the 
transverse  process  of  the  sixth  cervical  vertebra.  It  is  ac- 
companied by  a  vein  which  lies  in  front,  and  is  covered  by 
the  deep  cervical  fascia.  The  guide  to  it  is  the  carotid 
tubercle. 

Operation.  The  first  incision  is  the  same  as  for  ligature 
of  the  inferior  thyroid  (Fig.  18,  D).  The  anterior  edge  of 
the  sterno-cleido-mastoid  is  exposed  and  drawn  outward. 
The  middle  fascia  is  divided,  and  the  carotid  and  jugular 
drawn  inward.  The  gap  between  the  longus  colli  and  the 
scalenus  anticus  is  then  felt  for  about  half  an  inch  below 
the  carotid  tubercle,  the  deep  fascia  covering  it  torn  through, 
the  muscles  separated,  the  vertebral  vein  pushed  aside,  and 
the  artery  exposed. 

Chassaiguac  prefers  an  incision  along  the  posterior  border 

•  CeotralM.  flu  Chlrurgle,  1887,  p.  592. 


LIGATURE  OF  THE  ARTERIES.  41 

of  the  mastoid  muscle,  and  reaches  the  carotid  tubercle  by- 
drawing  the  muscle  aud  vessels  inward.  If  the  muscle  is 
very  broad  some  of  its  clavicular  fibres  must  be  divided. 


LIGATURE   OF    THE    AXILLARY    ARTERY. 

Anatomy.  The  axillary  extends  from  the  middle  of  the 
clavicle  to  the  lower  edge  of  the  tendon  of  the  teres  major. 
The  axillary  vein  lies  on  the  inner  side  and  in  front  of  it, 
aud  the  brachial  nerves  invest  its  lower  portion  closely.  It 
can  be  tied  below  the  clavicle  in  the  clavi-pectoral  triangle 
formed  by  the  clavicle,  inner  border  of  the  pectoralis  minor, 
and  the  thorax,  or  in  the  axilla.  The  strong  fascia  which 
unites  the  coracoid  process  and  clavicle,  and  forms  the  sus- 
pensory ligament  of  the  axilla,  the  costo-coracoid  fascia, 
sends  a  prolongation  about  the  upper  portion  of  the  axillary 
vein  which  keeps  its  walls  from  sinking  in  ;  the  cephalic 
vein  ascending  in  the  groove  between  the  deltoid  and  pec- 
toralis major  perforates  this  fascia  and  joins  the  axillary 
vein  at  the  inner  border  of  the  tendon  of  the  pectoralis 
minor,  close  by  the  origin  of  the  acromial  thoracic  artery. 

A.  Ligature  under  the  Clavicle  (Fig.  18,  JS.)  Make 
an  incision  extending  from  the  summit  of  the  coracoid  pro- 
cess four  or  four  and  a  half  inches  along  the  lower  border 
of  the  clavicle.  Divide  successively  the  skin,  subcutaneous 
tissue,  superficial  fascia,  and  pectoralis  major,  and  then  tear 
carefully  through  the  costo-coracoid  fascia,  avoiding  injury 
to  the  cephalic  vein  at  the  outer  part  of  the  wound.  The 
pectoralis  minor  is  now  exposed,  and  after  separating  the 
cellular  tissue  with  the  point  of  a  director  the  axillary  vein 
is  seen  crossing  from  the  upper  edge  of  the  muscle  to  the 
clavicle.  The  artery  is  completely  hidden  by  it,  lying  on 
the  outer  side  and  a  little  behind.  The  vein  must  now  be 
drawn  inward,  the  needle  entered  between  it  and  the  artery, 
and  the  ligature  applied  as  near  as  possible  to  the  clavicle 
on  account  of  the  proximity  of  the  acromial  thoracic  branch. 

B.  Ligature  in  the  Axilla.  Anatomy.  The  tissues  and 
organs  ou  the  outer  side  of  the  axilla  are  arranged  in  the 


42  OPERATIVE  SUJRGERY. 

following  order  :  (1)  the  skin  ;  (2)  the  subcutaneous  cellular 
tissue  ;  (3)  the  fascia  ;  (4)  the  axillary  vein  ;  (5)  the  internal 
cutaneous  and  ulnar  nerves;  (6)  the  axillary  artery;  (7)  the 
median  nerve;  (8)  the  coraco-brachialis;  (9)  the  humerus 
and  articular  capsule.  The  old  rule  for  exposing  the  artery 
here  was  to  make  a  longitudinal  incision  at  the  junction  of 
the  anterior  and  middle  thirds  of  the  axilla,  find  the  vein, 
count  two  nerves,  and  look  for  the  artery  just  beyond  the 
last  one.     This  is  a  difficult  and  dangerous  method,  and  a 

Fig.  19. 


H;y' 


h         J 

A.  Ligature  of  the  axillary  artery.    B.  Ligature  of  the  brachial  artery. 

much  simpler  one  has  beeu  substituted  by  Malgaignc,  who 
was  the  first  to  point  out  that  the  coraco-brachialis  muscle 
is  the  real  guide  to  the  artery. 

Operation.  The  arm  is  abducted  completely,  the  incision 
commenced  at  the  inner  border  of  the  coraco-brachialis  over 
the  head  of  the  humerus  and  carried  two  and  a  half  or 
three  inches  down  the  arm  parallel  to  the  course  of  the 
artery.  It  should  involve  the  skin  only,  so  as  to  avoid 
injury  to  the  basilic  vein.  If  the  edge  of  the  coraco-brachi- 
alis cannot  be  distinguished,  the  incision  should  be  made 
according  to  the  old  rule,  at  the  junction  of  the  inner  and 
middle  thirds  of  the  axilla.  The  aponeurosis  is  now  divided 
upon  a  director  over  the  coraco-brachialis, and  the  fibres  of 
the  inner  border  of  this  muscle  exposed.  The  parts  are 
then  relaxed  by  bringing  the  arm  nearer  the  trunk,  and  the 
posterior  side  of  the  wound,  including  the  vein,  ulnar  and 
internal  cutaneous  nerves,  is  drawn  back  with  a  retractor; 
and   the  artery,  overlain  by  the  median   nerve,  usually  ap- 


LIGATURE  OF  THE  ARTERIES. 


43 


pears  at  the  bottom,  covered,  perhaps,  by  the  posterior  part 
of  the  sheath  of  the  coraco-brachialis. 


LIGATURE    OF    THE    BRACHIAL    ARTERY. 

Anatomy.     The  brachial  artery  runs  from  the  junction 
of  the  anterior  and  middle  thirds  of  the  axilla  to  the  middle 


Fig.  20. 


Transverse  section  of  the  arm  at  its  middle  (Tii.la.ux). 
1.  Skin.  2.  Subcutaneous  tissue.  3.  Enveloping  aponeurosis  4.  Aponeurosis 
separating  the  anterior  and  posterior  loges  on  the  inner  side.  5.  Division  on  the 
outer  side.  6.  Brachial  artery  and  veins.  7.  Median  nerve.  S.  Basilic  vein. 
9.  Internal  cutaneous  nerve.  10.  Ulnar  nerve.  11.  Its  artery  and  veins.  12. 
Muscular  cutaneous  nerve.  13.  Muscular  spinal  nerve.  14.  Superior  profunda 
artery.    15.  Cephalic  vein. 

of  the  anterior  aspect  of  the  elbow.     It  occupies,  when  the 
forearm  is  supinated,  the  groove  between  the  biceps  and. 


44  OPERA  TI VE  SUE  GEE  Y. 

triceps,  being  partly  covered  by  the  former  in  muscular 
subjects,  aud  separated  from  the  bone  by  the  inner  edge  of 
the  eoraco-brachialis,  and  of  the  brachial  is  anticus.  It  lies 
in  the  anterior  loge  of  the  arm,  which  is  bounded  posteriorly 
on  this  side  by  a  prolongation  of  the  enveloping  aponeuro- 
sis, extending  down  to  the  bone  between  the  biceps  in  front 
aud  the  triceps  behind.  It  lies,  consequently,  within  the 
sheath  of  the  biceps,  and  the  inner  edge  of  this  muscle  is 
the  sure  guide  to  it.  It  lies  between  two  satellite  veins, 
which  anastomose  frequently,  and  has  the  median  nerve  in 
immediate  relation  with  it  on  the  side  next  the  skin.  The 
basilic  vein  directly  overlies  it  between  the  skin  and  the 
aponeurosis.  The  artery  presents  frequent  anomalies.  The 
most  common  is  its  premature  bifurcation  into  the  radial 
and  ulnar,  which  may  take  place  as  high  as  in  the  axilla, 
in  which  case  one  of  the  branches  is  superficial,  perhaps 
even  subcutaneous,  while  the  other  follows  the  usual  course. 
The  median  nerve  occupies  the  same  sheath  with  the  artery, 
lying  first  on  the  outer  side  and  then  crossing,  in  front  or 
behind,  very  obliquely  to  the  inner.  The  ulnar  nerve, 
accompanied  by  an  artery  and  two  veins,  lies  in  the  sub- 
stance of  the  triceps  immediately  behind  the  brachial  artery 
and  median  nerve,  separated  from  them  only  by  the  above- 
mentioned  prolongation  of  the  enveloping  aponeurosis,  and 
as  they  form  a  group  differing  from  the  other  only  in  size, 
the  artery  may  be  mistaken  for  the  brachial  if  met  with 
(Fig.  20).  This  error  will  not  be  made  if  the  fibres  of  the 
biceps  alone  are  exposed  and  the  incision  confined  to  the 
anterior  loge. 

Operation  Arm  abducted,  forearm  supinated.  Make 
an  incision  three  inches  long  in  the  middle  third  of  the  arm, 
along  the  inner  border  of  the  biceps  through  the  skin  and 
subcutaneous  cellular  tissue,  taking  care  not  to  injure  the 
basilic  vein,  which  should  be  kept  posterior  to  the  incision. 
Divide  the  aponeurosis  and  expose  the  fibres  of  the  biceps, 
if  the  muscle  is  large  draw  it  forward,  and  the  sheath  in- 
closing the  artery,  nerve,  and  veins  will  be  disclosed.  This 
is  turn  through  carefully  with  a  director,  the  median  nerve 
Separated  and  pushed  aside,  the  artery  separated  from  its 
veins,  and  the  ligature  passed  from  the  side  of  the  nerve. 


LIGATURE  OF  THE  ARTERIES.  45 

Fig.  21. 


Ligature  ot  the  brachial  artery. 

LIGATURE   OF   THE    RADIAL   ARTERY. 

Anatomy.  The  radial  artery  extends  in  a  straight  line 
from  a  point  half  an  inch  below  the  centre  of  the  fold  of 
the  elbow  to  the  ulnar  side  of  the  styloid  process  of  the 
radius ;  it  occupies  the  groove  bounded  on  one  side  by  the 
supinator  longus,  on  the  other  by  the  pronator  radii  teres 
and  flexor  carpi  radialis.  It  is  covered  only  by  the  skin, 
cellular  tissue,  and  aponeurosis ;  but  in  muscular  subjects 
the  muscular  interstice  in  which  it  lies  may  be  very  deep. 
It  is  accompanied  by  two  veins,  and  by  no  nerve.  It  occu- 
pies in  its  upper  third  the  sheath  of  the  pronator,  and  con- 
sequently the  fibres  of  the  supinator  longus  should  not  be 
exposed  in  the  search  for  the  artery,  although  the  edge  of 
the  muscle  may  be  taken  as  a  guide  to  it.  The  radial  nerve 
lies  within  the  sheath  of  the  supinator  longus,  and  at  first 
comes  quite  close  to  the  artery ;  it  then  passes  behind  and 
to  the  outer  side  of  the  tendon  of  the  muscle.  It  should 
not  be  seen  during  the  operation. 

Operation.  In  the  upper  third.  Make  an  incision  two 
and  one-half  inches  long  in  the  line  above  mentioned,  be- 
o-inniuff  one  and  one-half  inches  below  the  fold  of  the  elbow. 

•  •  • 

Avoiding  the  superficial  veins,  carry  the  incision  through 
the  cellular  tissue.  Recognize  the  edge  of  the  supinator 
longus,  and  divide  the  aponeurosis  along  the  ulnar  side  of 
it,  exposing  the  fibres  of  the  pronator.  Press  apart  the 
two  muscles  if  necessary,  separate  the  artery  from  its  veins, 
and  pass  the  ligature. 

3* 


46  OPERATIVE  SURGERY. 

In  the  lower  third  (Fig.  22).     Make  an  incision  in  the 

above-mentioned  line,  if  the  position  of  the  artery  cannot  be 

made  out  by  its  pulsations,  two  inches 

fig.  22.  long,  ending  an  inch  above  the  wrist. 

!  Divide  the  skin  and  cellular  tissue,  and 

J        then  the  fascia  carefully  upon  a  director. 

i  I        Separate  the  artery  from  the  two  veins, 

\       f  and  pass  the  ligature. 


LIGATURE  OF   THE   ULNAR   ARTERY. 

|_ A  Anatomy.     In  its  first  third  the  ulnar 

I  artery  passes  obliquely  underneath  the 

superficial  layer  of  muscles,  including 
the  superficial  flexor  of  the  fingers  to 
the  inner  side  of  the  arm,  where  it  be- 
comes superficial,  and  lies  between  the 
B  flexor  carpi  ulnaris  on  the  inside  aud 
the  flexor  sublimis  digitorum  on  the  out- 
I'i       If  side.     It  then  descends  to  the  wrist  in 

I    .  the  direction  of  a  line  uniting  the  inter- 

\  \        nal  condyle  of  the  humerus   with   the 

\  outer  border  of  the  pisiform  bone.  It 
Ligature  of  the  radial  is  accompanied  by  two  veins,  and  is 
and  ulnar  arteries.  joined  by  the  ulnar  nerve  just  before  it 
becomes  superficial,  the  nerve  lying  upon 
the  inner  or  ulnar  side  of  the  artery.  It  may  be  tied  at  any 
point  in  the  middle  and  lower  thirds.  As  the  deep  and  super- 
ficial flexors  of  the  fingers  are  separated  by  a  fascia,  and  as  the 
artery  lies  below  this  fascia,  it  is  covered  in  the  lower  part 
of  its  course  by  two  distinct  fascia?,  the  enveloping  fascia  of 
the  limb  and  this  second  one  which  unites  the  tendon  of  the 
flexor  carpi  ulnaris  with  those  of  the  flexors. 

Operation.  At  the  junction  of  the  upper  and  middle 
thirds.  Beginning  four  finger-breadths  below  the  internal 
condyle  of  the  humerus  make  an  incision  three  and  one-half 
or  four  indies  long  in  the  line  above  mentioned  (Fig.  22). 
Expose  the  enveloping  fascia  clearly,  and,  drawing  back 
the  posterior  lip  of  the  wound,  seek  the  first  muscular  inter- 
stice in   front  of  the  ulna.     It  is  that  between  the  flexor 


LIGATURE  OF  THE  ARTERIES.  47 

carpi  ulnaris  and  the  flexor  snblimis  digitornm,  aud  can  be 
recognized  by  the  finger  as  a  slight  depression,  or  by  the 
eye  as  a  white  line  under  the  fascia.  Divide  the  aponeu- 
rosis, beginning  at  the  lower  angle,  where  the  space  between 
the  muscles  is  broadest,  and  theu,  instead  of  following  the 
interstice  directly  backward,  raise  the  flexor  sublimis  and 
advance  transversely  across  the  arm  in  the  search  for  the 
artery  which  lies  upon  the  deep  flexor.  Isolate  the  artery, 
and  pass  the  needle  from  the  side  of  the  nerve. 

In  the  lower  third  (Fig.  22).  Make  an  incision  slightly 
to  the  radial  side  of  the  tendon  of  the  flexor  carpi  ulnaris, 
or  in  the  line  before  mentioned,  two  inches  long,  and  end- 
ing an  inch  above  the  end  of  the  ulna.  Divide  the  envel- 
oping fascia  upon  a  director,  and  tear  through  the  second 
over  the  vessel,  which  can  be  seen  and  felt  through  it. 
Isolate  the  artery,  and  pass  the  needle  from  within  outward 
so  as  to  avoid  the  nerve. 


LIGATURE    OF   THE    COMMON   CAROTID. 

The  place  of  election  for  ligature  of  the  common  carotid 
is  just  above  the  omohyoid  muscle,  but  the  lesion  which 
renders  the  ligature  necessary  may  require  it  to  be  applied 
at  a  much  lower  point.  The  vessel  has  been  tied  success- 
fully at  a  point  one-eighth  of  an  inch  from  its  origin  at  the 
bifurcation  of  the  innominata. 

The  steps  necessary  to  place  a  ligature  upon  the  common 
carotid  in  the  first  part  of  its  course  are  the  same  as  for 
ligature  of  the  first  portion  of  the  subclavian  or  of  the 
innominata  (q.  v.).  After  the  vessel  has  been  exposed, 
the  internal  jugular  is  pressed  to  the  outer  side,  the  artery 
denuded,  and  the  needle  passed  from  the  side  of  the  vein. 

At  the  place  of  election.  The  bifurcation  of  the  com- 
mon carotid  is  on  a  line  with  the  upper  border  of  the  thy- 
roid cartilage.  The  place  of  election  for  tying  it  is  about 
three-quarters  of  an  inch  below  its  bifurcation.  The  guide 
to  the  artery  is  the  anterior  border  of  the  sterno-cleido- 
mastoid  muscle,  and  the  danger  is  of  wounding  the  jugular 
vein,  which,  when  full,  entirely  covers  the  artery  on  the 
outer  side. 


48 


OPERA  TIVE  S URGER  Y. 


Operation.  Make  aloug  the  anterior  border  of  the  sterno- 
cleido-mastoid  an  incision  three  inches  in  length,  the  centre 
of  which  corresponds  with  the  crico-thyroid  space  (Fig.  23). 
Divide  the  skin,  platysma,  cellular  tissue,  and  aponeurosis, 
and  seek  for  the  interstice  between  the  sterno-cleido-mastoid 
and  the  sub-hyoid  muscles.  When  found,  the  latter  must 
be  pressed  inward,  and  the  artery  will  appear  at  the  edge  of 
the  sterno-cleido-mastoid,  the  vein,  which  is  external  to  it, 
remaining  covered.  The  artery  is  bared  with  a  director, 
and  the  needle  passed  from  without  inward. 

Fig.  23. 


Ligature  of  the  common  carotid  at  the  place  of  election. 

If,  instead  of  pressing  the  trachea  and  its  muscles  inward, 
the  mastoid  is  drawn  outward,  the  vein  is  exposed,  almost 
completely  overlying  the  artery,  and,  by  its  presence  and 
the  necessity  of  handling  it,  increases  the  difficulty  and 
danger  of  the  operation. 


LIGATURE   <>K   THE    EXTERNAL   CAROTID. 


The  free  anastomoses  which  exist  within  the  cranium  be- 
tween the  two  internal  carotids  render  ligature  of  the 
common  carotid  insufficient  to  arrest  hemorrhage  from  the 


LIGATURE  OF  THE  ARTERIES.  49 

external  carotid  ;  the  ligature  must  be  applied  to  the  vessel 
itself,  despite  the  number  of  its  branches  aud  the  difficulty 
of  recognizing  them  at  the  bottom  of  the  incision.  The 
operation  is  a  difficult  one,  for  there  are  many  important 
organs  to  be  avoided,  and  there  is  no  direct  guide  to  the 
vessel . 

Anatomy.  The  comon  carotid  divides  opposite  the  upper 
border  of  the  thyroid  cartilage  (a  little  lower  in  females) 
into  the  external  and  internal  carotids,  which  occupy  nearly 
the  same  autero-posterior  plane,  the  former  being  in  front. 
At  about  three-quarters  of  an  inch  above  the  bifurcation 
the  arteries  cross,  the  external  becoming  posterior,  the  inter- 
nal anterior.  The  internal  carotid  gives  off  no  branches 
outside  the  cranium,  while  the  external  gives  off  eight.  Of 
these  the  superior  thyroid  arises  at  or  very  near  the  bifur- 
cation, the  lingual,  facial,  ascending  pharyngeal,  and  occi- 
pital near  the  point  where  the  artery  passes  under  the 
digastric,  about  an  inch  above  the  bifurcation,  the  others  at 
a  considerable  distance  above.  The  hypoglossal  nerve  loop- 
ing around  the  occipital  artery  at  its  origin  crosses  the  ex- 
ternal carotid  to  the  hyoid  bone,  sending  a  branch,  the 
descendens  noni,  down  the  outside  of  the  artery. 

There  are  thus  three  means  of  distinguishing  the  external 
carotid  :  (1)  its  branches;  (2)  its  position  with  reference  to 
the  internal  carotid ;  (3)  its  immediate  relations  with  the 
hypoglossal  nerve,  the  internal  carotid  occupying  a  deeper 
plane.  In  a  search  for  the  external  carotid  the  operator 
may  be  satisfied  with  either  of  these  guides,  accordingly  as 
one  or  the  other  presents  itself.  Should  the  nerve  be  first 
encountered,  he  will  tie  the  vessel  upon  which  it  lies;  should 
both  vessels  lie  at  the  bottom  of  the  incision,  he  will  know 
that  the  anterior  one  is  the  external  carotid ;  and  if  the 
vessel  which  he  isolates  has  a  branch,  he  knows  it  caunot 
be  the  internal  carotid. 

Although  the  force  of  the  objection  has  been  greatly 
diminished  by  the  employment  of  antiseptic  silk  or  catgut 
ligatures,  which  admit  of  primary  union  throughout  the 
wound,  it  is  still  desirable  that  the  ligature  should  be  ap- 
plied at  a  distance  from  branches  of  considerable  size;  and 
from  this  point  of  view  the  first  half-inch  of  the  artery  and 
the  portion  underlying  the  digastric  are  the  places  of  elec- 


50  OPERATIVE  SURGERY. 

tion,  and  of  these  two  the  former  alone  is  practicable.  The 
connective  tissne  surrounding  the  two  arteries  at  their  origin 
is,  however,  unusually  compact,  rendering  their  denudation 
so  difficult  that  any  search  for  branches  would  be  dangerous 
to  the  nutrition  of  the  vessel's  wall. 

M.  Guyon1  has  shown  that,  while  the  lingual  and  superior 
thyroid  arteries  vary  greatly  in  their  points  of  origin,  the 
average  distance  between  them  is  from  12  to  18  millimetres, 
or  over  half  an  inch  ;  he  calls  the  portion  of  the  vessel 
between  them  the  "  trunk  of  the  external  carotid,"  and  sug- 
gests that  the  ligature  should  be  applied  6  mm.  below  the 
point  at  which  the  hypoglossal  nerve  crosses  the  artery,  this 
nerve  being,  in  the  great  majority  of  cases,  in  immediate 
relation  with  the  origin  of  the  lingual  artery.  Dolbean,  in 
his  report  upon  this  paper,  advises  that  the  superior  thyroid 
should  also  be  tied,  and  that  the  carotid  should  be  sought 
for  from  below  upward  instead  of  from  above  downward, 
on  account  of  the  greater  depth  of  its  upper  portion  and 

Fig.  24. 


f 


'  ■■■■ 


i 

Ligature  of— A.  Lingual  artery.    B,  External  carotid.     C.  Occipital. 
D.  Temporal.    E.  Facial. 

the  supposition  of  large  veins.    M.  Guyon  collected  twenty- 
four  cases  of  ligature  of  the  external  carotid  without  espe- 

1  Momoirs  de  la  Soc.  de  Chirurgie,  1864,  p.  555. 


LIGATURE  OF  THE  ARTERIES.  51 

cial  reference  to  the  proximity  of  branches,  and  in  only  one 
of  them  did  secondary  hemorrhage  occur. 

Operation.  When  the  head  is  extended  and  the  face 
turned  to  the  opposite  side,  an  incision  carried  from  the  angle 
of  the  jaw  to  the  anterior  border  of  the  sterno-cleido-mas- 
toid  opposite  the  top  of  the  thyroid  cartilage  will  cross  the 
artery  obliquely  (Fig.  24,  B).  It  must  be  carried  through  the 
skin,  platysma,  and  subcutaneous  cellular  tissue,  the  exter- 
nal jugular  being  drawn  aside  when  encountered.  The 
superficial  fascia  is  then  divided  in  the  line  of  the  incision, 
care  being  taken  not  to  deviate  to  the  right  or  left,  and  the 
deeper  and  denser  layer  then  torn  through  with  the  director. 
When  the  artery  has  been  exposed  and  cleaned,  the  needle 
is  passed  from  behind  forward. 

The  lymphatic  glands  of  the  region  are  numerous  and 
often  large,  and  may  be  mistaken  for  the  artery.  There  is 
no  objection  to  removing  any  that  may  interfere  with  the 
search  for  the  vessel. 


LIGATUEE    OF    THE    INTEENAL   CAEOTID. 

This  is  to  be  done  according  to  the  method  described  for 
the  external  carotid. 


LIGATUEE    OF    THE    LINGUAL    AETEEY. 

Anatomy.  The  lingual  artery  arises  from  the  external 
carotid,  on  a  level  with  the  great  horn  of  the  hyoid  bone, 
and  passes  between  the  middle  constrictor  of  the  pharynx 
and  the  hyoglossus  upward  and  forward.  It  is  occasion- 
ally accompanied  by  a  small  vein,  but  the  lingual  vein  is 
separated  from  it  by  the  thickness  of  the  hyoglossus  muscle. 
Its  one  important  branch,  the  sublingual,  sometimes  has  its 
origin  at  or  near  the  point  where  the  lingual  is  usually  tied, 
and  may  be  mistaken  for  it.  The  artery  may  be  tied  near 
its  origin,  between  the  great  horn  of  the  hyoid  bone  and 
the  posterior  belly  of  the  digastric,  but  its  depth  at  this 
point,  and  the  presence  of  large  veins,  make  the  operation 
difficult  and  dangerous.     The  place  of  election  is  in   the 


52 


OPERATIVE  SURGERY. 


triangle  bounded  posteriorly  by  the  posterior  belly  of  the 
digastric,  anteriorly  by  the  posterior  border  of  the  mylo- 
hyoid, and  above  by  the  hypoglossal  nerve.  It  is  covered 
at  this  point  by  the  skin,  platysma,  cervical  aponeurosis, 
submaxillary  gland,  and  the  hyoglossus  muscle,  the  fibres 
of  which  form  the  floor  of  the  triangle  just  described. 

Operation.     Make  a  curved  incision  two  inches  long,  its 
concavity  directed  upward,  its  centre  one-quarter  of  an  inch 


Fig.  25. 

AROTID  GLANo 


Occipital  a 


Facial  a. 

Mylo-hyoid  n. 

Submental  a. 


Hypoglossal  n 

Descendens  noni  n 
Lingual  a. 


Internal  jugular  v. 
Superior  thyroid  a 


Common  carotid  a. 


Anatomical  relations  of  the  lingual  and  facial  arteries. 

above  the  hyoid  bone  at  a  point  midway  between  the  median 
line  and  the  extremity  of  the  great  horn  (Fig.  24,  A). 
Divide  the  skin  and  platysma,  pushing  the  superficial  veins 
aside,  and  then  the  cervical  aponeurosis,  which  may  be  very 
thin.  liaise  the  submaxillary  gland,  find  the  posterior  belly 
of  the  digastric,  its  attachment  to  the  hyoid  bone,  the  pos- 
terior border  of  the  mylohyoid,  and  the  hypoglossal  nerve 
accompanied  by  the  lingual  vein.     Draw  the  hyoid  bone 


LIGATURE  OF  THE  ARTERIES.  53 

slightly  downward  with  a  blunt  hook  fixed  in  the  lower 
angle  of  the  triangle  bounded  by  these  organs,  and  then, 
pinching  up  the  fibres  of  the  hyoglossus  with  a  pair  of  for- 
ceps, divide  them  carefully  along  a  line  parallel  to  the 
nerve,  and  midway  between  it  and  the  boue.  As  the  cut 
fibres  retract,  the  artery  is  disclosed  below  them  ;  separate 
it  from  its  vein,  if  there  be  one,  and  pass  the  ligature. 


LIGATURE    OP    THE    FACIAL    ARTERY. 

The  facial  artery  crosses  the  inferior  maxilla  just  in  front 
of  the  anterior  edge  of  the  masseter,  from  which  it  is  sepa- 
rated by  the  facial  vein  (Fig.  25).  A  depression,  in  which 
it  is  lodged,  can  usually  be  felt  on  the  lower  edge  of  the 
bone.  The  artery  can  be  exposed  by  a  vertical  incision 
along  its  course,  or  by  a  horizontal  one  along  the  lower 
border  of  the  maxilla. 

Operation  (Fig.  24,  E)  Beginning  at  the  lower  edge  of 
the  maxilla,  make  an  incision  one  inch  iu  length  along  the 
course  of  the  artery;  divide  the  skin,  subcutaneous  tissue, 
aud  fascia ;  separate  the  artery  from  the  vein  and  pass  the 
needle  between  them. 

If  the  horizontal  iucision  is  used,  it  should  extend  three- 
quarters  of  an  inch  on  each  side  of  the  artery,  the  anterior 
edge  of  the  masseter  should  be  recognized,  and  the  vessel 
sought  for  immediately  in  front  of  it. 


LIGATURE    OF    THE    OCCIPITAL    ARTERY. 

At  the  Mastoid  Process.  The  guides  to  frhe  vessel  are  the 
apex  and  posterior  border  of  the  mastoid  process,  the  digas- 
tric groove  on  its  inner  surface,  and  the  digastric  muscle. 

Operation  (Fig.  24,  (?).  Starting  from  a  point  half  an 
inch  below  and  in  front  of  the  apex  of  the  mastoid  process, 
carry  the  incision  two  inches  obliquely  backward  parallel  to 
the  border  of  this  process.  Divide  the  skin  and  enveloping 
fascia,  and  then  the  sterno-mastoid  and  its  insertion  through- 
out the  entire  length  of  the  incision.  Then  divide  the  sple- 
nius  and  its  shining  aponeurosis,  and  feel  for  the  digastric 


54  OPERATIVE  SURGERY. 

groove.  Pinch  up  and  carefully  divide  a  thin  fascia  which 
covers  the  anterior  face  of  the  splenitis.  Starting  from  the 
belly  of  the  digastric,  separate  the  cellular  tissue  in  the 
anterior  angle  of  the  wound  with  a  director,  denude  the 
artery  and  tie.     (Chauvel.) 


LIGATURE   OF    THE    TEMPORAL    ARTERY. 

(Fig.  24,  D.)  Make  a  transverse  incision  one  inch  long, 
extending  from  the  tragus  of  the  ear  forward  over  the  zygo- 
matic arch.  Separate  the  subcutaneous  cellular  tissue,  which 
is  very  dense  and  fibrous,  with  a  director,  and  seek  the  artery 
imbedded  in  it  about  a  quarter  of  an  inch  in  front  of  the 
ear.  Press  the  vein  backward,  pass  the  needle  from  behind 
forward,  taking  care  not  to  include  in  the  ligature  the  tem- 
poral branch  of  the  auriculo-temporal  nerve,  which  is  some- 
times in  close  relations  with  the  artery. 


LIGATURE   OF   THE   ABDOMINAL   AORTA. 

This  operation  has  been  performed  about  a  dozen  times, 
with  a  fatal  result  in  each  case.  The  patients  survived  for 
periods  varying  from  a  few  hours  to  ten  days.  The  artery 
may  be  reached  through  the  abdominal  cavity  by  an  incision 
in  the  median  line,  or,  without  dividing  the  peritoneum,  by 
an  incision  in  the  flank  similar  to  Konig's  for  extirpation 
of  the  kidney  (q.  v.).  The  objection  to  the  former  is  the 
danger  consequent  upon  exposure  of  the  peritoneal  sac  and 
its  contents,  but  the  steadily  improving  results  of  abdominal 
surgery  show  that  this  is  not  exceptionally  great.  On  the 
other  hand,  the  application  of  a  ligature,  even  under  the 
most  favorable  circumstances,  after  the  artery  has  been  ex- 
posed by  the  other  method,  requires  the  utmost  dexterity, 
the  chance  of  exciting  peritonitis  is  great,  and,  finally,  the 
presence  of  the  aneurism  and  the  displacements  and  adhe- 
sions it  has  caused  may  render  it  impossible  to  reach  the 
vessel. 

Operation.  Through  the  Peritoneal  Cavity.  An  incision 
in  the  linea  alba,  extending  from  a  point  three  inches  above 


LIGATURE  OF  THE  ARTERIES  55 

the  umbilicus  to  one  three  inches  below  it,  and  curving  to 
one  side  to  avoid  the  umbilicus.  Divide  the  peritoneum 
upon  a  director,  press  the  intestines  aside,  tear  through  the 
peritoneum  covering  the  aorta  with  the  finger-nail,  separate 
the  uerves  from  its  anterior  surface,  and  pass  the  ligature 
from  the  outer  side.  Cut  both  ends  short,  and  close  the 
external  wound  as  in  ovariotomy. 


LIGATURE   OF   THE   COMMON   ILTAC. 

Anatomy  of  the  Common,  Internal,  and  External  Iliae 
Arteries.  The  aorta  bifurcates  usually  on  the  left  side  of 
the  fourth  lumbar  vertebra,  and  the  direction  of  the  com- 
mon and  external  iliacs  is  represented  by  a  line  drawn  from 
a  point  an  inch  above  the  umbilicus  to  another  one-half  an 
inch  external  to  the  centre  of  Poupart's  ligament.  The 
common  iliac  is  usually  two  inches  long,  and  bifurcates  at 
the  sacro-iliac  synchondrosis,  but  it  must  be  remembered 
that  this  bifurcation  may  take  place  at  any  point  between 
one  and  a  half  and  three  or  even  four  inches  from  the  origin 
of  the  artery.     The  common  iliac  gives  off  no  branches. 

The  external  iliac  runs  downward  and  outward  along  the 
brim  of  the  pelvis  from  the  bifurcation  to  a  point  under 
Poupart's  ligament  midway  between  the  anterior  superior 
spine  of  the  ilium  and  the  symphysis  pubis.  Its  two 
branches,  the  epigastric  and  circumflex  ilii,  are  given  off 
nearly  opposite  each  other,  a  short  distance  above  Poupart's 
ligameut,  sometimes  much  higher. 

The  internal  iliac  runs  downward  and  backward  into  the 
pelvis  for  one  and  a  half  inches,  dividing  at  the  upper  border 
of  the  great  sacro-sciatic  foramen  into  two  large  trunks. 
The  ureter  crosses  the  vessels  at  or  just  below  the  bifurca- 
tion of  the  common  iliac,  the  vas  deferens  two  and  a  half 
or  three  inches  lower.  Both  are  more  closely  adherent  to 
the  peritoneum  than  to  the  arteries.  The  iliac  veins  lie 
upon  the  inner  side  and  posterior  to  the  arteries  ;  both  pass 
behind  the  right  common  iliac,  the  right  vein  at  its  bifur- 
cation, the  left  vein  much  higher  up.  The  spermatic  ves- 
sels and  ffenito-crural  nerve  lie  iu  front  of  the  external  iliac 


56  OPERATIVE  SURGERY. 

at  the  lower  part  of  its  course,  and  the  circumflex  iliac  vein 
crosses  it  at  the  same  place. 

The  abdominal  wall  at  the  point  where  the  incisions  are 
made  is  composed  of  the  following  layers  in  the  order 
named :  skin,  subcutaneous  cellular  tissue,  fascia,  external 
oblique  or  its  aponeurosis,  internal  oblique,  transversalis, 
and  transversalis  fascia. 

Extraperitoneal  Operation.  Beginning  at  a  point  a 
finger's  breadth  above  Poupart's  ligament  and  just  outside 
of  the  external  iliac  artery,  make  an  incision  four,  five,  or 
six  inches  in  length,  according  to  the  thickness  of  the 
abdominal  wall,  parallel  at  first  to  Poupart's  ligament,  and 
curving  upward  after  passing  the  anterior  superior  spine  of 
the  ilium  (Fig.  26).     Divide  the  skin,  subcutaneous  tissue, 

Fig.  26. 


Ligature  of—  A.  Common  iliac.    B.  External  iliac. 
C.  Femoral  iu  Scarpa's  space. 

and  fascia,  exposing  the  aponeurosis  of  the  external  oblique ; 
divide  the  latter  upon  a  director  throughout  the  whole 
extent  of  the  incision,  and  then  divide  the  fibres  of  the 
internal  oblique  and  transversalis  in  the  same  manner,  or 
by  pinching  them  up  with  the  forceps  and  cutting  carefully 
with  repeated  slight  touches  of  the  knife,  until  the  fascia 
transversalis,  which  varies  much  in  density,  is  exposed. 
Raise  the  fascia  at  the  lower  angle  of  the  wound,  where  it 
is  most  dense,  with  forceps,  and  make  a  hole  in  it  large 
enough  to  admit  the  finger.     Pass  the  forefinger  through 


LIGATURE  OF  THE  ARTERIES.  57 

this  hole,  press  back  the  peritoneum  with  it,  and  enlarge 
the  hole  upward  in  the  line  and  to  the  full  extent  of  the 
incision,  the  finger  being  kept  between  the  peritoneum  and 
the  knife. 

The  peritoneum  is  now  raised  from  the  psoas  and  iliacus 
muscles  and  drawn  upward  and  inward  by  an  assistant, 
while  the  operator  seeks  for  the  external  iliac  and  passes 
the  forefinger  of  his  left  hand  along  it  to  the  common  iliac, 
the  thighs  being  flexed  to  relax  the  abdominal  walls.  As 
it  is  seldom  that  a  good  view  of  the  artery  can  be  obtained, 
the  finger  must  be  kept  upon  it,  and  the  loose  cellular  tissue 
in  which  it  is  imbedded  very  gently  separated  with  the 
point  of  a  director  or  the  finger-nail.  When  the  artery 
has  been  properly  cleaned,  pass  the  needle  from  within 
outward. 

Intra-peritoneal  Operation.  Open  the  abdomen  in  the 
median  line  by  an  incision  extending  from  the  symphysis 
pubis  to  or  a  little  above  the  umbilicus,  and,  after  pushing 
aside  the  intestines  with  flat  sponges  or  pads,  tear  through 
the  peritoneum  overlying  the  artery  and  pass  the  ligature 
from  within  outward. 

Care  must  be  taken  not  to  include  the  ureter,  which 
usually  crosses  the  vessel  at  its  point  of  bifurcation.  In 
the  extra-peritoneal  operation  there  is  less  clanger  of  this 
accident,  as  the  ureter  is  adherent  to  the  peritoneum,  and 
is  lifted  out  of  the  way  as  this  membrane  is  stripped  up. 


LIGATURE    OF    THE    INTERNAL    ILIAC. 

Its  accompanying  vein  lies  behind  and  on  the  inner  side. 

Extra-peritoneal  Operation.  Same  as  for  ligature  of  the 
common  iliac.  After  the  peritoneum  has  been  lifted  up, 
the  finger  is  passed  along  the  external  iliac  to  the  bifurca- 
tion, and  then  downward  for  half  an  inch  along  the  internal 
iliac.  The  vein  being  carefully  protected,  the  artery  is 
bared,  and  the  ligature  passed  from  within  outward. 

The  intra-peritoneal  operation1  does  not  differ  enough 

1  Dr.  F.  S.  Dennis  discusses  this  operation  in  its  application  to  spontaneous 
gluteal  and  sciatic  aneurisms  in  the  Medical  News,  Nov.  20,  18S6. 


58  OPERATIVE  SURGERY. 

from  that  for  tying  the  common  iliac  to  require  a  separate 
description. 

Ligature  of  the  iuterual  iliac  has  beeu  seldom  employed, 
except  for  traumatic  gluteal  aneurism,  and  in  these  cases, 
as  Professor  Van  Buren1  has  pointed  out,  the  treatment 
should  be  to  cut  down  upon  the  sac,  and  tie  both  ends  of 
the  artery,  hemorrhage  being  controlled  by  digital  pressure 
made  upon  the  internal  iliac  from  within  the  rectum. 


LIGATURE    OF   THE    EXTERNAL    ILIAC. 

Various  cutaneous  incisions  have  been  recommended  for 
this  operation.  Sir  Astley  Cooper's  extended  from  the 
external  abdominal  ring  to  within  a  short  distance  of  the 
superior  spine  of  the  ilium  ;  the  objections  to  it  are  that  it 
involves  the  division  of  the  superficial  epigastric,  and,  per- 
haps, of  the  internal  epigastric  also,  and  that  the  ligature 
can  be  applied  only  to  the  lower  part  of  the  artery.  Aber- 
nethy's  extended  outward  from  the  internal  inguinal  ring 
parallel  to  Poupart's  ligament;  by  it  the  vessel  is  reached 
at  a  greater  depth,  but  it  has  the  great  advantage  of  allow- 
ing extension,  so  that  if  it  should  prove  necessary  the  liga- 
ture may  be  applied  even  to  the  common  iliac.  By  curving 
the  outer  portion  of  the  incision  upward  away  from  the 
superior  spine  of  the  ilium,  the  main  branches  of  the  cir- 
cumflex ilii  may  be  avoided. 

Operation.  Beginning  over  the  outer  side  of  the  artery 
a  finger's  breadth  above  Poupart's  ligament,  make  an  in- 
cision three  or  four  inches  in  length,  at  first  parallel  with 
Poupart's  ligament,  and  then  curving  upward  (Fig.  26). 
Carry  this  incision  through  the  abdominal  wall,  and  raise 
the  peritoneum  from  the  surface  of  the  iliacus  and  psoas 
muscles  in  the  same  manner  as  for  ligature  of  the  common 
iliac.  Flex  the  thighs  so  as  to  relax  the  abdominal  muscles, 
and,  while  an  assistant  draws  the  peritoneum  and  the  con- 
tained intestines  upward  and  inward,  seek  the  artery  upon 
the  inner  border  of  the  psoas.  Clean  it  with  a  director  or 
pair  of  forceps,  and  pass  the  needle  from  within  outward. 

For  the  intra-peritoneal  operation  an  incision  along  the 


1876 


1  Report  on  "Aneurism,"  Proceedings  of  the  International  Medical  Congress, 


LIGATURE  OF  THE  ARTERIES. 


59 


lower  part  of  the  linea  semilunaris  would  generally  be 
better  than  one  in  the  median  line. 


LIGATURE    OF    THE    GLUTEAL,    SCIATIC,    AND    INTERNAL 
PUDIC   ARTERIES. 

The  proper  treatment  of  injury  to  either  of  these  arteries 
is  to  enlarge  the  wound  and  tie  both  ends  of  the  divided 
vessel,  but  it  may  happen  that  this  would  be  impossible, 

Fig.  27. 


Ligature  of—  A.  Gluteal  artery.    B.  Sciatic  and  internal  pudic. 

and  that  ligature  in  continuity  is  required.  The  necessary 
incisions  are  those  shown  in  Fig.  27.  The  place  at  which 
the  gluteal  artery  emerges  from  the  great  sciatic  notch  may 
be  roughly  stated  as  opposite  a  point  at  the  junction  of  the 
upper  and  middle  thirds  of  a  line  joining  the  posterior 
superior  spine  of  the  ilium  with  the  great  trochanter. 

The  sciatic,  where  it  crosses  the  spine  of  the  ischium,  lies 
opposite  the  junction  of  the  middle  and  lower  thirds  of  a 
line  joining  the  tuberosity  with  the  posterior  superior  spine 
of  the  ilium. 

After  division  of  the  skin  and   fascia,  the  fibres  of  the 


60  OPERATIVE  SURGERY. 

gluteus  maximus  are  separated  and  held  apart  with  long 
retractors,  the  deep  fascia  torn  through,  and  the  artery 
sought  for. 

The  gluteal  artery  is  to  be  sought  for  above  the  pyri- 
formis  muscle  at  the  upper  border  of  the  great  sacro- sciatic 
notch,  where  it  can  be  felt  near  a  small  bony  tubercle.  It 
is  covered  by  many  large  veins,  which  require  very  careful 
handling.  The  ligature  should  be  applied  as  close  to  the 
notch  as  possible. 

The  sciatic  and  internal  pudic  arteries  leave  the  great 
sciatic  notch  at  the  lower  edge  of  the  pyriformis  ;  the  former 
divides  almost  immediately,  the  latter  re-enters  the  pelvis 
through  the  lesser  sacro-sciatic  notch,  lying  on  the  inner 
side  of  the  sciatic  artery  during  its  passage  over  the  spine 
of  the  ischium. 


LIGATURE    OF   THE    FEMORAL    ARTERY. 

Anatomy.  The  femoral  artery  is  the  continuation  of  the 
external  iliac,  and  extends  in  a  straight  line  from  a  point 
midway  between  the  anterior  superior  spine  of  the  ilium 
and  the  symphysis  pubis  to  the  ring  in  the  tendon  of  the 
adductor  magnus  about  four  finger-breadths  above  the  tuber- 
cle  of  insertion  of  that  muscle  on  the  upper  portion  of  the 
inner  condyle  of  the  femur.  In  the  first  one  or  two  inches 
of  its  course  it  gives  off  the  superficial  external  pudic,  epi- 
gastric, and  circumflex  ilii,  and  the  much  larger  and  more 
important  profunda  arteries.  The  anastomotica  magna  arises 
near  its  lower  end.  The  artery  is  accompanied  throughout 
by  the  femoral  vein,  which,  at  first,  lies  upon  the  inner  side, 
and  then  becomes  posterior.  They  are  separated  at  first 
by  a  distinct  septum,  which  disappears  in  the  lower  third. 
The  anterior  crural  nerve  emerges  from  below  Pou  part's 
ligament,  about  half  an  inch  external  to  the  artery  ;  it 
divides  up  rapidly,  and  one  of  its  branches,  the  internal  or 
long  saphenous,  enters  the  sheath  of  the  vessels  three  or 
four  inches  below  the  groin,  and  leaves  it  again  after  the 
artery  has  entered  Hunter's  canal ;  this  name  being  given 
to  the  condensed  sheath  for  a  short  distance  above  and  below 
the  point  when;  it  passes  through  the  tendon  of  the  adduc- 


LIGATURE  OF  THE  ARTERIES.  Q\ 

tor  magous.  The  artery  passes  under  the  sartorius  at  about 
the  junction  of  its  upper  and  middle  thirds. 

Ligature  of  the  femoral  above  the  origin  of  the  profunda 
has  proved  unsatisfactory,  and  has  been  generally  aban- 
doned for  that  of  the  external  iliac.  The  artery  may  be 
tied  at  any  part  of  its  course,  but  the  point  generally  chosen 
is  at  the  apex  of  Scarpa's  triangle,  next  that  in  the  middle 
of  the  thigh,  and,  lastly,  in  Hunter's  canal. 

Operation.  A.  At  the  Apex  of  Scarpa's  Triangle  (Figs. 
26  and  28).     Make  an  incision  three  or  four  inches  long, 


.•..•■.•.••■■••"•.••''•' 


Fig.  28. 


-~. 


■m^ 


Ligature  of  the  femoral  artery. 


the  centre  of  which  shall  be  a  little  above  the  point  where 
the  inner  border  of  the  sartorius  crosses  a  line  drawn  from 
the  middle  of  Pou part's  ligament  to  the  inner  tuberosity  of 
the  femur.  The  internal  saphenous  vein  should  be  out  of 
danger  on  the  inner  side  of  the  incision.  Divide  the  skin, 
subcutaneous  tissue,  and  the  fascia  lata,  exposing  the  fibres 
of  the  sartorius,  which  may  be  recognized  by  their  direction 
downward  and  inward,  those  of  the  adductors,  on  the  con- 
trary, being  downward  and  outward.  The  limb  should  now 
be  slightly  flexed,  the  vessels  recognized  by  the  touch  at  the 
inner  border  of  the  sartorius,  this  muscle  drawn  outward, 
and  the  sheath  of  the  vessels  pinched  up  with  forceps  on  the 
outer  side  (the  vein  lying  on  the  inner)  and  opened.  The 
needle  is  then  passed  from  within  outward. 

B.  In  the  Middle  of  the  Thigh.     Here  the  vessel  lies 
underneath  the  sartorius  which  overlaps  it  ou  both  sides. 

4 


62  OPERATIVE  SURGERY. 

The  incision  is  made  in  the  line  above  mentioned,  its  centre 
being  a  little  above  the  middle  of  the  thigh  ;  the  sartorius 
is  exposed  and  drawn  outward  after  the  leg  has  been  further 
flexed.  The  vessel  is  then  sought  for,  exposed,  and  tied  as 
before. 

C.  In  Hunter's  Canal.  Abduct  and  flex  the  thigh,  and 
rotate  it  outward  so  as  to  make  the  adductors  tense;  feel 
for  the  tendon  of  the  adductor  magnus  and  make  au  incision 
three  or  four  inches  long,  the  centre  of  which  is  at  the 
junction  of  the  lower  and  middle  thirds  of  the  thigh,  in  the 
direction  of  the  tendon,  which  is  that  of  a  liue  drawn  from 
the  spine  of  the  pubis  to  the  tubercle  on  the  inner  condyle 
of  the  femur.  Divide  the  skin  and  subcutaneous  tissue 
carefully  so  as  not  to  wound  the  internal  saphenous  vein, 
and  then  the  aponeurosis  upon  a  director.  Recognize  the 
fibres  of  the  sartorius  and  of  the  vastus  internus  which  are 
at  right  angles  with  one  another,  and  by  pressing  the  former 
inward  or  the  latter  outward  the  tendon  of  the  adductor 
and  the  curved  glistening  fibres  arching  from  it  to  the  vas- 
tus internus  are  exposed.  If  the  saphenous  nerve  is  now 
encountered  it  should  be  traced  upward,  a  director  passed 
into  the  orifice  through  which  it  emerges,  and  the  aponeurosis 
divided  upward;  if  the  nerve  is  not  seen  it  should  not  be 
sought  for,  but  the  aponeurosis  should  be  pinched  up  and 
divided  close  to  the  tendon  of  the  adductor.  The  sheath  of 
the  vessels  is  now  opened,  and  the  artery  is  separated  from 
the  closely  adherent  vein.  The  needle  should  be  passed 
from  within  outward. 

Some  surgeons  prefer  to  make  the  first  incision  in  the 
direction  of  the  artery  rather  than  in  that  of  the  tendon. 


LIGATURE    OF   THE    POPLITEAL    ARTERY. 

This  is  an  operation  which  is  required  only  in  the  rare 
cases  of  rupture  of  the  artery  when  an  attempt  is  to  be 
made  to  save  the  limb.  The  artery  lies  very  deep  between 
the  condyles  of  the  femur,  imbedded  in  fat,  and  directly 
covered  by  the  vein,  the  walls  of  which  are  thick  and  stiff 
like  those  of  an  artery.     The  short  saphenous  vein  perfor- 


LIGATURE  OF  THE  ARTERIES.  63 

ates  the  fascia  near  the  centre  of  the  popliteal  space,  and 
empties  into  the  main  trunk. 

Operation.  Make  an  incision  three  or  four  inches  long 
in  the  vertical  diameter  of  the  popliteal  space,  the  centre  of 
which  shall  correspond  to  the  point  at  which  the  ligature  is 
to  be  placed.  Divide  the  skin  and  cellular  tissue,  taking 
care  not  to  injure  the  saphenous  vein,  and  then  the  aponeu- 
rosis to  the  full  extent  of  the  cutaneous  incision.  Flex  the 
leg,  have  the  sides  of  the  wound  drawn  widely  apart,  and 
work  down  through  the  fat  and  lymphatic  glands  to  the 
artery,  leaving  first  the  nerve  and  then  the  vein  upon  the 
outer  side.  Protecting  the  vein  with  one  finger,  denude  the 
artery  and  pass  the  needle  from  without  inward. 

Jobert  (de  Lamballe)  reached  the  popliteal  artery  in  the 
upper  part  of  its  course  by  an  incision  on  the  inner  aspect 
of  the  leg,  passing  between  the  tendon  of  the  adductor 
raagnus  on  one  side,  and  the  sartorius,  semi-membranosus, 
and  semi-tendinosus  on  the  other.  The  artery  is  found  lying 
close  to  the  femur. 


LIGATURE    OF   THE    ANTERIOR    TIBIAL    ARTERY. 

Anatomy.  After  perforating  the  interosseous  membrane 
at  the  upper  part  of  the  leg,  the  anterior  tibial  runs  in  a 
direction  which  is  that  of  a  line  drawn  upon  the  anterior 
aspect  of  the  leg  from  the  upper  tibio-fibular  articulation 
to  a  point  midway  between  the  malleoli.  It  lies  at  first 
between  the  belly  of  the  tibialis  anticus  and  that  of  the 
extensor  communis  digitorum  upon  the  interosseous  mem- 
brane, afterward  between  the  tibialis  anticus  and  the  exten- 
sor proprius  pollicis  or  their  tendons  upon  the  tibia.  It  is 
accompanied  by  two  veins  and  the  anterior  tibial  nerve, 
which  latter  lies  first  upon  the  outer  side  and  then  crosses  in 
front  to  the  inner  side.  It  may  be  tied  at  any  point  in  its 
course. 

Operation  Make  in  the  above-mentioned  line  an  inci- 
sion the  kngth  of  which  will  vary  according  to  the  depth 
at  which  the  artery  is  placed.  Divide  the  skin  and  cellular 
tissue,  lay  bare  the  fascia,  and  divide  it  along  the  first  mus- 
cular interstice,  which  shows  as  a  white  line  under  it ;  make 


64 


OPERATIVE  SURGERY. 


also  a  transverse  incision  through  the  fascia  from  the  middle 
of  the  longitudinal  one  to  the  crest  of  the  tibia,  so  as  to 
give  more  room.     Flex  the  foot  upon  the  leg,  separate  the 


Fig.  29. 


Transverse  section  of  the  leg,  upper  third.  (Tii.laux.) 
T.  Tibia.  F.  Fibula.  EF.  Enveloping  fascia.  DF.  Deep  fascia  dividing  to 
inclose.  PT.  Posterior  tibial  artery  and  nerve,  and  PA.  Peroneal  artery.  TA. 
Tibialis  anticus  muscle.  AT.  Anterior  tibial  artery  and  nerve.  IM.  Interosseous 
membrane.  P.  Peroneus  longus  muscle.  IS.  Internal  saphenous  vein.  ES 
External  saphenous  vein  and  nerve. 


muscles  from  below  upward  with  the  ringer,  draw  them 
apart  with  retractors,  isolate  the  artery  without  raising  it, 
and  pass  the  needle  from  the  side  of  the  nerve. 


LIGATURE  OF  THE  ARTERIES.  65 


LIGATURE    OF   THE    DORSALIS    PEDIS. 

This  artery  is  the  continuation  of  the  anterior  tibial,  and 
passes  through  the  posterior  end  of  the  first  metatarsal  space 
to  the  plantar  aspect  of  the  foot.  It  lies  on  the  outer  side 
of  the  tendon  of  the  extensor  proprius  pollicis,  and  is 
crossed  in  its  lower  portion  by  the  inner  tendon  of  the  ex- 
tensor brevis.  It  is  covered  by  the  skin,  superficial  fascia, 
the  edge  of  the  extensor  brevis,  or  its  tendon,  and  a  deep 
fascia.  Its  direction  is  that  of  a  line  drawn  from  a  point 
midway  between  the  malleoli  to  the  posterior  end  of  the 
first  metatarsal  space.  The  incision  should  be  in  this  line, 
and  the  tendon  of  the  extensor  proprius  pollicis  should  be 
left  on  the  inner  side. 


LIGATURE    OF   THE    POSTERIOR    TIBIAL. 

The  posterior  tibial  artery  in  its  upper  and  middle  por- 
tions lies  upon  the  tibialis  posticus  and  the  flexor  communis 
digitorum,  and  is  covered  by  the  soleus,  from  which  it  is 
separated  by  the  deep  fascia.  Near  the  ankle  it  is  covered 
only  by  the  integument  and  fascia.  In  its  upper  portion 
it  can  be  reached  by  two  routes:  (1)  the  one  employed  by 
Guthrie,  and  approved  of  by  Spence  and  Holmes,  through 
the  middle  of  the  calf;  (2)  the  one  in  more  common  use, 
from  the  inner  side  of  the  calf. 

Operation  (Guthrie).  Beginning  at  the  lower  angle  of 
the  popliteal  space,  make  an  incision  six  inches  in  length 
directly  downward,  avoiding  as  far  as  possible  the  super- 
ficial veins,  carry  this  incision  through  the  soleus,  divide 
the  deep  fascia,  separate  the  artery  from  the  vein  and  nerve, 
which  are  superficial  to  it,  and  pass  the  needle  from  their 
side. 

Lateral  Method.  Beginning  in  the  middle  of  the  upper 
third  of  the  leg,  make  an  incision  from  four  to  five  inches 
long,  parallel  to  and  half  an  inch  behind  the  inner  border 
of  the  tibia.  Carry  the  incision  down  to  the  fascia,  leav- 
ing the  internal  saphena  on  the  tibial  side;  divide  the  fascia, 
draw  the  gastrocnemius  backward,  and  separate  the  soleus 


66 


OPERATIVE  SURGERY, 


at  its  attachment  to  the  tibia,  leaving  the  deep  fascia  attached 
to  the  bone.  Raise  the  heel  and  flex  the  leg  upon  the  thigh, 
draw  back  the  calf,  enlarge  the  incision  if  necessary,  seek 
the  artery  and  tear  carefully  through  the  deep  fascia  over  it ; 
isolate  the  artery,  leaving  the  nerve  on  the  outer  side,  and 
pass  the  needle  between.  Tillaux1  has  proposed  a  modifi- 
cation.    Instead  of  detaching  the  soleus  from  the  tibia,  he 


Fig.  30. 


'•■  „\V" 


Fig.  31. 


Ligature  of  the  anterior  tibial  artery.  Ligature  of  the  posterior  tibial  artery. 

passes  between  it  and  the  gastrocnemius,  and  then  divides 
the  former  muscle  longitudinally  over  the  course  of  the 
artery.  If  this  incision  does  not  at  once  expose  the  artery, 
the  vessel  must  be  sought  for  on  one  side  or  the  other  by 
pressing  back  the  sides  of  the  incision. 

The  centre  of  the  soleus  is  occupied  by  an  intra-muscular 
septum  parallel  to  the  deep  fascia,  and  sometimes  so  stout 


1  Anatomie  Topographique,  Paris,  1877,  p.  1145. 


LIGATURE  OF  THE  ARTERIES.  67 

as  to  be  mistaken  for  it.  Close  attention  is  required  for 
the  avoidance  of  this  error. 

In  the  Loiver  Third  and  Behind  the  Ankle.  The  artery 
lies  midway  between  the  tendo  Achillis  and  the  inner  edge 
of  the  tibia  or  the  malleolus,  and  is  covered  by  the  super- 
ficial and  deep  fascia?,  the  latter  of  which  forms  the  annular 
ligament  at  the  ankle. 

Operation.  Midway  between  the  tendo  Achillis  and 
inner  edge  of  the  tibia,  or  a  finger's  breadth  behind  the 
latter,  make  an  incision  three  inches  long  parallel  to  the 
tibia,  if  the  ligature  is  to  be  placed  above  the  ankle,  or  a 
curved  line  parallel  to  the  posterior  border  of  the  malleolus, 
if  it  is  to  be  placed  behind  the  ankle.  Seek  the  bundle  of 
vessels,  tear  through  the  deep  fascia  covering  them,  taking 
care  not  to  open  the  tendinous  sheaths  which  lie  in  front, 
and  pass  the  needle  from  without  inward. 


/ 


PART  III. 

AMPUTATIONS. 


Amputations  may  be  in  continuity  (through  the  bone), 
or  in  contiguity  (through  a  joint) ;  to  the  latter  the  term 
disarticulation  is  usually  applied.  The  methods  of  opera- 
tion are  classified  as  circular,  oval,  aud  flap,  and  the  choice 
of  a  method  is  determined  by  the  disposition  of  the  soft 
parts  about  the  bone,  the  facility  with  which  the  joint  can 
be  opened  in  a  disarticulation,  the  form  of  the  resulting 
stump,  and  the  position  of  the  cicatrix.  The  comparative 
merits  of  these  methods  and  their  various  modifications 
will  be  discussed  in  connection  with  the  different  opera- 
tions. They  may  be  essentially  modified  by  accidental 
circumstances,  and  by  the  necessity  which  sometimes  arises, 
as  in  cases  of  injury,  of  fashioning  the  flap  from  such  tis- 
sues as  are  available. 


CIRCULAR   METHOD. 

1st  Time.  The  cutaneous  incision  .should  be  made  at  a 
distance  below  the  point  where  the  bone  is  to  be  divided 
equal  to  two-thirds  of  the  diameter  of  the  limb  at  that  point. 
While  an  assistant  draws  the  skin  firmly  and  evenly 
toward  the  root  of  the  limb,  the  operator  passes  his  hand 
below  and  beyond  it,  and  places  the  heel  of  the  knife  upon 
its  upper  surface,  its  point  directed  toward  his  own  shoulder. 
lie  then  sweeps  the  knife  entirely  around  the  limb,  divid- 
ing the  skin  and  subcutaneous  cellular  tissue,  down  to  the 
enveloping  fascia,  and  terminating  the  incision  at  the  point 
where  it  began. 


AMPUTATIONS.  69 

2d  Time.  a.  The  skin  and  cellular  tissue  are  retracted 
and  the  muscles  divided  in  succession,  the  deeper  ones  at 
higher  levels,  so  that  the  surface  of  section  forms  a  cone, 
the  apex  of  which  is  directed  upward.  The  muscles  whose 
origins  are  most  distant  must  be  cut  long  to  allow  for  their 
greater  retraction. 

b.  {Alanson's  method)  The  point  of  the  knife  is  passed 
obliquely  down  from  the  edge  of  the  skin  to  the  bone  at 
the  point  where  it  is  to  be  divided,  and  carried  around  the 
limb,  always  at  the  same  angle  with  the  bone,  so  as  to  form 
the  muscular  cone  by  a  single  incision. 

c.  [Cutaneous  sleeve.)  The  skin  and  cellular  tissue  are 
separated  cleanly  from  the  deep  fascia  and  turned  back 
over  the  limb,  the  raw  surface  outward.  The  sleeve  thus 
formed  is  lengthened  by  drawing  it  up  and  dividing  its 
attachments  to  the  fascia,  care  being  taken  to  include  all  the 
subcutaneous  cellular  tissue  in  it,  until  the  dissection  has 
nearly  reached  the  height  at  which  the  bone  is  to  be  divided. 
The  fascia  and  muscles  are  then  cut  through  to  the  bone 
transversely  with  a  single  sweep  of  the  knife,  held  as  for 
making  the  cutaneous  incision. 

3d  Time.  Division  of  the  Bone.  The  soft  parts  being 
drawn  up  and  protected  by  a  piece  of  leather  or  a  cotton 
band  four  inches  wide  and  two  feet  long,  split  for  half  its 
length  so  as  to  pass  on  each  side  of  the  bone  (called  the 
retractor),  and  the  periosteum  having  been  divided  circu- 
larly with  the  knife  along  or  a  little  below  the  line  to  be 
traversed  by  the  saw,  the  operator  peaces  the  heel  of  the 
saw  upon  the  bone,  steadies  its  edge  with  the  thumb-nail 
of  his  left  hand,  and  draws  it  slowly  toward  himself,  cut- 
ting a  deep  groove  in  the  bone ;  he  then  completes  the 
division  with  a  few  rapid  strokes  of  the  instrument,  while 
the  limb  is  firmly  held  by  two  assistants,  so  as  to  prevent 
binding  of  the  saw  or  splintering  of  the  bone.  The  peri- 
osteum may  first  be  dissected  up  for  half  an  inch,  so  as 
to  form  a  sort  of  curtain  to  overhang  the  end  of  the  bone. 

If  there  are  two  bones  the  retractor  should  be  split  into 
three  instead  of  two  parts,  and  the  central  one  passed  be- 

4* 


70  OPERATIVE  SURGERY. 

tween  the  bones.  The  saw  should  be  first  applied  to  the 
larger  bone,  and,  after  cutting  a  deep  groove  in  it,  should  be 
inclined  backward  or  forward,  so  as  entirely  to  divide  the 
second  before  completing  the  division  of  the  first. 


OVAL    METHOD. 

A  scalpel  is  used  instead  of  the  amputating  knife ;  the 
incision  is  commenced  at  the  level  at  which  the  bone  is  to 
be  divided,  is  carried  downward  on  one  side,  across  the  back 
of  the  limb,  and  upward  ou  the  opposite  side  to  the  point 
at  which  it  began.  The  details  will  be  given  in  connection 
with  certain  disarticulations  to  which  this  method  is  especi- 
ally applicable. 

FLAP    METHOD. 

The  flaps  may  be  single  or  double,  antero- posterior,  bilat- 
eral, long  rectangular  (Teale),  or  skin  flaps  with  circular 
division  of  the  muscles  (modified  flap  operation).  They 
may  be  made  by  transfixion  or  from  without  inward.  In 
making  a  flap  by  transfixion  it  is  well  first  to  mark  its  out- 
line by  an  incision  through  the  skin  and  cellular  tissue  with 
a  scalpel,  as  otherwise  there  is  danger  of  making  its  point 
too  narrow  or  its  edges  jagged.  The  point  of  the  amputat- 
ing knife  is  then  entered  at  the  nearest  angle  of  the  incision 
and  passed  through  to  the  other,  hugging  the  bone  on  its 
way,  and  the  cut  made  steadily  downward  and  outward, 
with  sawing  movements  of  the  knife.  It  is  then  re-entered 
and  brought  out  at  the  same  points,  but  passing  on  the 
opposite  side  of  the  bone,  and  the  second  flap  cut  in  the 
same  manner  as  the  first.  The  fibres  on  each  side  of  the  bone 
which  have  escaped  are  then  divided,  the  retractor  applied, 
and  the  bone  sawed  through  as  above. 

In  cutting  a  flap  from  without  inward  the  scalpel  must 
be  entered  at  one  of  the  angles  of  the  base  of  the  proposed 
flap,  carried  along  a  curved  line  down  to  the  apex  of  the 
flap,  and  thence  up  to  the  other  angle  of  the  base.  The 
presence  of  a  tumor,  or  injury  to,  or  disease  of,  the  soft 
parts  may  render  it  necessary  to  modify  the  shape  of  the 


AMPUTATIONS.  71 

flap  or  vary   the   obliquity  of  the  incision,  so  as  not  to 
include  any  unfit  tissue  in  the  former. 

Skin  Flaps  and  Circular  Division  of  the  Muscles.  In 
this  operation  the  flaps  include  only  the  skin  and  subcuta- 
neous cellular  tissue  dissected  off  from  the  deep  fascia  ;  the 
latter  and  the  muscles  are  divided  transversely  by  a  sweep 
of  the  knife  at  the  base  of  the  flap,  the  retractor  applied, 
and  the  bone  cleaned  and  divided  a  little  higher  up. 

Long  Anterior  Flap.  An  anterior  flap,  its  length  some- 
what greater  than  the  antero-posterior  diameter  of  the  limb 
at  its  base,  is  cut  by  transfixion,  or  from  without  inward ; 
the  posterior  muscles  and  segment  of  skin  are  cut  straight 
across  a  little  below  the  point  of  division  of  the  bone,  and 
the  anterior  flap  brought  down  to  cover  their  cut  surface. 
This  method  furnishes  a  good  covering  for  the  bone,  free 
drainage  for  the  secretions  of  the  wound,  and  a  well-placed 
cicatrix. 

In  every  amputation  it  is  well  to  dissect  out  the  main 
nerve  trunks,  and  cut  them  off  high  up  between  the  muscles, 
so  that  their  ends  may  not  become  imbedded  in  the  cicatrix 
or  involved  in  the  suppuration. 

The  choice  of  one  or  another  method  will  often  be  deter- 
mined by  the  anatomical  and  pathological  circumstances  of 
the  case.  When  any  one  may  be  used,  the  preference  is 
usually  given  now  to  the  skin  flap  with  circular  division  of 
the  muscles. 

Teale's  Method.  In  the  method  to  which  Mr.  Teale's 
name  has  been  given  a  very  long  rectangular  anterior  flap, 
comprising  half  the  circumference  of  the  limb  and  all 
the  tissues  down  to  the  bone,  is  made  aud  doubled  back 
upon  itself,  thus  furnishing  a  thick  pad  for  the  bone  and 
a  posterior  cicatrix.  The  method  of  operating  is  as  fol- 
lows :  (Fig.  46,  B)  A  rectangular  anterior  flap  (posterior  in 
the  forearm),  equal  in  length  and  breadth  to  half  the  cir- 
cumference of  the  limb  at  the  base  of  the  flap,  is  marked 
out  by  one  transverse  and  two  parallel  longitudinal  inci- 
sions, the  latter  involving  only  the  skin,  the  former  being 
carried  down  to  the  bone.    The  lougitudinal  incisions  should 


72  OPERATIVE  SURGERY. 

be  so  placed  that  the  principal  vessels  and  nerves  will  not  be 
included  in  this  flap,  but  in  the  posterior  one,  which  is  also 
bounded  by  a  transverse  incision  carried  down  to  the  bone, 
and  is  only  one-fourth  as  long  as  the  anterior  one.  The  two 
flaps  are  now  in  turn  dissected  up  close  to  the  bone,  and  the 
saw  applied  at  their  base.  After  the  vessels  have  been 
secured  the  long  flap  is  doubled  back  upon  itself,  and  its 
square  end  fastened  to  that  of  the  other  with  sutures ;  two 
or  three  points  of  suture  are  also  required  to  keep  the  sides 
of  the  short  flap  and  of  the  reversed  portion  of  the  long- 
flap  in  contact  with  the  rest  of  the  latter. 

It  is  found  that  by  retraction  of  the  short  posterior  flap 
the  cicatrix  is  drawn  up  behind  and  out  of  the  way  of  the 
bone,  and  that  a  soft  mass  without  any  large  vessels  or 
nerves  is  the  result  of  the  partial  atrophy  of  the  long  flap, 
and  forms  an  excellent,  non-sensitive  stump.  The  principal 
objection  to  this  method,  and  one  which  greatly  restricts  its 
applicability,  is  the  great  length  of  the  anterior  flap,  which 
can  be  obtained  in  many  cases  only  by  dividing  the  bone 
at  a  much  higher  point  than  would  otherwise  be  necessary. 


AMPUTATION    OF    THE    FINGERS. 

Phalanges.  When  the  injury  or  disease  is  limited  to 
one  or  two  fingers,  and  it  is  of  such  a  nature  that  the  mem- 
ber will  be  useless,  if  preserved,  the  affected  phalanx  or 
finger  should  be  removed  without  hesitation  ;  but  usually 
it  is  desirable  to  save  as  much  as  possible  of  the  parts,  and 
therefore  whenever  a  choice  can  be  made  amputation  in 
continuity  is  to  be  preferred  to  disarticulation  higher  up. 
The  incisions  should  be  so  arranged  that  the  cicatrix  will 
not  lie  upon  the  palmar  surface,  and  for  this,  as  well  as  for 
anatomical  reasons,  the  principal  flap  should  be  taken  from 
the  flexor  aspect.  No  special  directions  are  required  for 
amputation  or  disarticulation  of  the  middle  and  distal  pha- 
langes. For  amputation  through  the  shaft  the  incision  may 
be  circular  with  a  longitudinal  addition  one-third  of  an  inch 
long  on  each  side,  or  the  single  anterior  flap  by  transfixion 
may  be  used.  In  disarticulation  it  is  best  to  enter  the  joint 
from  the  dorsal  side  with  a  narrow-bladed  knife,  and  cut 


AMP  VTA  TIONS.  73 

the  anterior  flap  by  carrying  the  knife  through  the  joint 
and  then  forward,  hugging  the  bone. 

It  must  be  remembered  that  the  folds  on  the  palmar  sur- 
face of  a  finger  do  not  correspond  exactly  to  the  joints  ;  the 
first  being  half  an  inch  beyond,  the  middle  one  a  line  above, 
and  the  distal  one  a  quarter  of  an  inch  above  the  articular 
surfaces,  and  also  that  the  prominence  of  a  knuckle  when 
the  finger  is  flexed  is  formed  entirely  by  the  head  of  the 
proximal  and  not  by  the  base  of  the  distal  phalanx.  When 
the  tissues  have  not  become  thickened  and  infiltrated  the 
articular  depressions  can  also  be  felt  upon  the  sides. 

Amputation  through  the  Metacarpophalangeal  Articula- 
tion. The  articular  depression  can  be  found  very  easily  by 
passing  the  thumb  and  forefinger  along  the  sides  of  the 
finger,  especially  if  the  latter  be  at  the  same  time  drawn 
forcibly  away  from  its  metacarpal  bone. 

The  incision  should  be  commenced  over  the  dorsum  of 
the  metacarpal  bone  a  quarter  of  an  inch  above  the  articu- 
lation, carried  through  the  interdigital  web,  and  then  back 
on  the  palmar  face  to  a  point  a  quarter  of  an  inch  above 
the  flexor  fold  (Fig.  32,  C) ;  a  similar  incision,  beginning 
and  ending  at  the  same  points,  is  made  on  the  other  side  of 
the  finger,  the  flaps  dissected  back,  the  lateral  ligaments 
divided  while  the  finger  is  drawn  first  to  one  side  and  then 
to  the  other  so  as  to  facilitate  access  to  them  and  at  the 
same  time  make  them  tense,  and  then  the  tendon^and  the 
remainder  of  the  capsule  divided  as  the  finger  is  with- 
drawn. 

Or  an  incisiou  may  be  made  only  on  the  side  correpond- 
ing  to  the  right  hand  of  the  operator,  the  flap  dissected 
back  to  the  joint,  the  lateral  ligament  divided,  the  knife 
carried  transversely  through  the  joint,  dividing  the  tendons 
and  the  other  lateral  ligament,  and  the  other  flap  cut  from 
within  outward,  care  being  taken  to  make  it  sufficiently 
broad. 

The  head  of  the  metacarpal  bone  should  be  removed  only 
in  cases  where  it  is  more  desirable  to  diminish  the  deformity 
than  to  preserve  the  strength  of  the  hand. 

An  artery  on  each  side  will  have  to  be  secured,  and  the 
wound  closed  with  sutures. 


74 


OPERATIVE  SURGERY. 


The  incisions  may  be  advantageously  modified  for  the 
index  and  little  fingers  by  making  a  full  lateral  flap  on  the 
free  side  and  carrying  the  incision  transversely  across  the 
palmar  surface  to  the  angle  of  the  web,  and  thence  obliquely 
back  to  the  knuckle  (Fig.  32,  E). 


AMPUTATION    OF    THE    METACARPAL    BONES. 

As  the  articulations  of  the  first  and  fifth  metacarpal  bones 
with  the  carpus  do  not  communicate  with  the  other  and 


A.  Disarticulation  of  the  phalanx,  anterior  llap.  B.  Amputation  in  contin- 
uity, circular.  C.  Metacarpo-phalangcal  disarticulation.  D.  Amputation  of  a 
metacarpal  bone  in  continuity.  K,  Disarticulation  of  little  finger.  F.  Disartic- 
ulation of  fifth  metatarsal.  Q.  Amputation  of  wrist,  circular.  77.  Amputation 
of  wrist.    (Dubrueil.) 


larger  synovial  sacs,  these  bones  may  be  entirely  removed 
without  much  danger  of  sotting  up  inflammation  within  the 


AMPU1ATI0NS.  75 

wrist-joint,  but  in  the  case  of  the  other  three  amputation 
in  continuity  is  preferable  to  disarticulation.  The  relations 
of  the  synovial  sheaths  of  the  flexor  tendons  are  also  of 
importance  in  the  operation.  There  is  no  communication 
between  the  main  sheath  in  the  palm  of  the  hand  and  the 
sheaths  of  the  second,  third,  and  fourth  fingers,  and  con- 
sequently, if  the  tendons  are  divided  as  low  down  as  the 
metacarpo-phalangeal  articulation,  inflammation  of  the 
main  sheath  with  all  its  disastrous  consequences  will  prob- 
ably be  avoided. 

The  incisions  are  the  same  as  for  amputation  through  the 
metacarpo-phalangeal  articulation,  with  a  prolongation  up- 
ward as  far  as  may  be  necessary  over  the  back  of  the  bone 
(Fig.  32,  D).  After  its  posterior  and  lateral  surfaces  have 
been  bared,  the  bone  is  cut  through  with  pliers  at  the  point 
determined  on,  or  disarticulated  from  the  carpus,  and  the 
distal  fragment  is  raised  from  its  bed,  and,  beginning  at  the 
upper  end,  its  under  surface  carefully  separated  from  the 
soft  parts. 

In  disarticulation  of  the  fifth  metacarpal,  the  incision 
should  be  made  along  the  inner  border  of  the  hand,  and 
carried  down  to  the  bone  between  the  skin  and  the  abductor 
minimi  digiti  rather  than  through  the  fibres  of  the  latter 
(Fig.  32,  F).  This  gives  easier  access  to  the  palmar  liga- 
ments uniting  the  bone  to  the  carpus.  The  lower  end  of 
the  incision  should  form  a  loop  with  its  centre  in  the  inter- 
digital  web,  and  its  point  on  the  line  of  the  knuckle. 
I 

c 

AMPUTATION    AT   THE   WEIST. 

(Radio-carpal  Disarticulation.) 

Circular  Method  (Fig.  32,  G).  While  an  assistant  re- 
tracts the  skin  upon  the  forearm,  the  operator  sweeps  his 
knife  transversely  around  the  wrist,  half  an  inch  below  the 
point  of  the  styloid  process  of  the  radius.  The  skin  and  as 
much  cellular  tissue  as  possible  are  divided  and  dissected 
back  as  far  as  the  joint,  which  is  then  opened  by  entering 
the  point  of  the  knife  just  below  the  styloid  process  of  the 


76  OPERATIVE  SURGERY. 

radius,  and  the  disarticulation  completed  while  the  hand  is 
drawn  firmly  away  from  the  arm. 

Antero-posterior  Flaps.  The  absence  of  muscular  fibres 
at  the  wrist  deprives  this  method  of  most  of  the  advantages 
which  it  offers  at  other  points,  and  the  projection  on  the 
palmar  surface  of  the  trapezium  and  pisiform  bones  renders 
its  execution  difficult,  and  makes  it  practically  identical 
with  the  circular  method  supplemented  by  lateral  incisions. 
It  should  be  reserved  for  cases  in  which  the  skin  is  so  infil- 
trated that  it  cannot  be  readily  dissected  back. 

An  incision  curved  downward  is  carried  across  the  back 
of  the  wrist  from  one  styloid  process  to  the  other,  the  flap 
dissected  up,  the  hand  flexed  forcibly,  the  extensor  tendons 
divided,  the  joint  opened  beneath  them,  and  the  palmar  flap, 
which  should  extend  as  far  down  as  the  base  of  the  meta- 
carpal boues,  cut  from  within  outward. 

Or  the  palmar  flap  may  be  made  from  without  inward, 
or  by  transfixion,  before  the  joint  has  been  opened. 

External  Lateral  Flap.  Dubrueil1  (Fig.  32,  H).  The 
hand  is  pronated,  and  the  operator  makes  a  curved  incision, 
which,  beginning  on  the  dorsal  aspect  a  quarter  of  an  inch 
below  the  radio-carpal  articular  line,  at  the  junction  of  the 
outer  and  middle  thirds,  passes  downward,  crosses  the  outer 
side  of  the  first  metacarpal  bone  at  its  centre,  and  returns  to 
a  point  on  the  palmar  surface  opposite  that  at  which  it 
began.  Its  two  ends  are  then  joined  by  a  transverse  inci- 
sion passing  around  the  inner  side  below  the  end  of  the  ulna. 
The  external  flap  is  dissected  up,  the  joint  opened  at  the 
radial  side,  and  the  disarticulation  completed. 


AMPUTATION    OF   THE    FOKEARM. 

The  forearm  may  be  divided,  with  reference  to  surgical 
considerations,  into  upper,  middle,  and  lower  thirds.  Its 
shape  is  cylindrical  near  the  elbow,  and  gradually  flattens 
and  narrows  toward  the  wrist.    The  lower  half  of  the  radius 

1  Mcdeeine  Operatoire,  ]>.  171. 


AMPUTATIONS.  77 

and  the  whole  length  of  the  ulna  are  subcutaneous.  The 
coverings  of  the  lower  third  are  composed  almost  exclusively 
of  skin  and  tendons,  while  thick  muscular  masses  cover  the 
upper  two  thirds,  especially  on  the  anterior  aspect.  The 
absence  of  suitable  coverings  in  the  lower  third,  aud  the 
presence  there  of  so  many  synovial  sheaths,  the  inflamma- 
tion of  which  may  give  rise  to  dangerous  complications, 
have  led  some  surgeons  (Baron  Larrey,  Sedillot)  to  advise 
strongly  against  amputating  at  this  part.  On  the  other 
hand,  it  is  important  for  the  subsequent  usefulness  of  the 
limb  that  the  movements  of  pronation  and  supination  should 
be  preserved,  and  this  can  only  be  done  by  dividing  the 
bones  below  the  insertion  of  the  pronator  radii  teres,  which 
is  just  above  the  middle  of  the  radius;  if  the  division  has 
to  be  made  above  this  point  the  rule  is  to  save  as  much  as 
possible,  especially  the  insertion  of  the  biceps. 

For  the  reasons  stated,  the  only  method  applicable  to  the 
lower  third  is  the  circular  one,  and  if  the  conicity  of  the 
limb  or  the  infiltration  of  the  parts  should  otherwise  render 
it  impossible  to  carry  the  dissection  of  the  cutaneous  sleeve 
to  a  sufficient  height,  the  circular  incision  must  be  supple- 
mented by  a  short  longitudinal  one  in  front.  The  division 
of  the  tendons  should  be  on  the  same  level  with  that  of  the 
bone,  and  is  best  accomplished  by  passing  the  knife  under 
them,  and  cutting  directly  outward. 

In  the  upper  two-thirds  the  difficulty  of  dissecting  a 
cutaneous  sleeve  is  l'kely  to  be  still  greater,  and  has  led  to 
general  rejection  of 'the  circular  method.  On  the  other 
hand,  lateral  flaps  are  impossible,  and  the  bones  have  a 
tendency  to  project  at  the  angles  if  antero-posterior  flaps 
are  made.  Many  methods  have  been  proposed  to  obviate 
this  difficulty,  in  all  of  which  the  essential  point  is  the  same, 
namely,  to  divide  the  bones  at  least  half  an  inch  above  the 
angles  of  the  incision  through  the  skin.  Sedillot  made  short 
thin  musculo-cutaneous  flaps,  and  divided  the  deep  muscles 
obliquely  according  to  Alanson's  method  (p.  69) ;  Richet 
makes  short  flaps,  including  all  the  soft  parts,  dissects  them 
up  circularly  from  the  bones  for  about  three  quarters  of  au 
inch,  and  divides  the  latter  at  the  height  thus  reached. 
Tillaux  recommends  short  skin  flaps  to  be  dissected  up  for 
three-quarters  of  an  inch  above  their  base,  and  then  short 


78  OPERATIVE  SURGERY. 

muscular  flaps  to  be  made  parallel  to  the  former  by  trans- 
fixion at  the  higher  level.  When  there  is  sufficient  avail- 
able material  ou  the  back  of  the  arm  for  a  long  flap,  Teale's 
method  gives  good  results. 

High  up  in  the  upper  third,  where  the  position  of  the 
bones  is  more  central,  and  thick  muscular  masses  lie  upon 
the  sides,  the  short  flaps  should  be  lateral. 


AMPUTATION    AT   THE    ELBOW-JOINT. 

The  guides  to  the  articulation  are  the  epitrochlea  on  the 
inuer,  the  epicondyle  and  the  head  of  the  radius  ou  the 
outer  side.  The  smooth  rounded  prominence  formed  by 
the  latter  can  be  readily  felt  about  half  an  inch  below  the 
epicondyle ;  aud  the  interarticular  line  starting  from  it 
passes  at  first  transversely  and  then  downward  aud  inward 
toward  a  point  an  inch  below  the  epitrochlea,  and  forms  an 
angle,  opening  inward,  with  the  transverse  diameter  of  the 
lower  end  of  the  humerus.  It  is  therefore  unnecessary  to 
expose  the  epicondyle  and  epitrochlea  in  disarticulating ; 
and  these  relative  positions  should  be  constantly  kept  in 
mind  during  the  operation.  The  skin  is  freely  movable  in 
front,  but  is  adherent  to  the  ulna  behind. 

The  methods  in  common  use  are  the  iuterior  flap,  lateral 
flap,  and  circular. 

Anterior  Flap.  The  joint  may  be  opened  (a)  from  be- 
hind, or  (b)  from  in  front. 

a.  From  behind.  (Sedillot.)  The  forearm  is  flexed,  and 
an  incision,  slightly  convex  downward  and  interesting  only 
the  posterior  third  of  the  circumference,  is  made  one  and  a 
half  inches  below  the  tuberosities  of  the  humerus.  The 
skin  is  dissected  up  to  the  tip  of  the  olecranon,  the  tendon 
of  the  triceps  divided,  the  point  of  the  knife  passed  into 
the  joint  and  carried  first  to  one  side  and  then  to  the  other, 
cutting  the  posterior  and  lateral  ligaments.  A  longitudinal 
incision  two  and  a  half  inches  long  is  then  carried  down- 
ward from  the  outer  end  of  the  first,  the  forearm,  still  flexed, 
is  pressed  backward  and  inward,  and  the  disarticulation 
readily  completed   bypassing  the  knife  through  the  joint, 


AMPUTATIONS. 


79 


and  cutting  down  and  out  on  the  anterior  aspect  while  the 
skin  is  forcibly  retracted. 

b.  From  in  front.  (Fig.  33,  A.)  The  flap  may  be  made  by 
transfixion,  or  from  without  inward  ;  in  either  case  it  should 
be  at  least  three  inches  long,  and  its  base  should  be  par- 
allel to  and  three-quarters  of  an  inch 
below  a  line  drawn  through  the  epi- 
condyle  and  the  epitrochlea.  Some 
surgeons  prefer  to  make  the  line  of 
the  base  oblique  downward  and  out- 
ward, because  the  muscles  on  the 
outer  side  have  their  origins  at  higher 
points  on  the  humerus,  and  retract 
more  than  those  on  the  inner  side. 
The  posterior  incision  should  be 
slightly  convex  downward,  and 
should  begin  and  end  at  the  same 
points  as  the  anterior  one. 

The  head  of  the  radius  is  then 
sought  for,  and  the  joint  opened  by 
entering  the  knife  between  it  and 
the  humerus  and  completely  divid- 
ing the  external  lateral  ligament. 
The  capsule  is  divided  in  front  by 
passing  the  point  of  the  knife  along 
the  edge  of  the  ulna  over  the  coro- 
noid  process  to  the  internal  lateral 
ligament,  which  should  be  cut  as 
high  as  possible.  The  olecrauon  is 
disengaged  from  the  humerus  by 
drawing  it  down  forcibly,  the  attach- 
ment of  the  triceps  divided,  the  knife  passed  behind  the 
bone,  and  the  remaining  tissues  divided  from  within  out- 
ward. 


Amputation  at  the  elbow- 
joint.  A.  Anterior  flap.  B. 
External  flap.  C.  Circular 
method. 


Lateral  flap.  (Fig.  33,  B.)  An  external  flap  four  or 
five  inches  long  is  made  by  transfixion  from  a  point  in  the 
median  line  in  front,  a  finger's  breadth  below  the  bend  of 
the  elbow ;  or  from  without  inward  by  an  incision  begin- 
ning at  the  same  point  and  ending  half  an  inch  higher  on. 


80  OPERATIVE  SURGERY. 

the  posterior  face  of  the  ulna.  A  second  iucision  is  made 
transversely  across  the  inner  side  of  the  arm  about  an  inch 
below  the  upper  end  of  the  first.  The  radio-humeral  joint 
is  opened,  and  the  disarticulation  completed  as  before. 

Instead  of  a  single  external  flap,  two  lateral  flaps  may 
be  made,  but  the  external  should  be  half  au  inch  longer 
than  the  internal  one. 

Circular.  (Fig.  33,  0.)  An  incision,  transverse  or  a 
little  lower  on  the  outer  than  on  the  inner  side,  is  made 
about  the  limb  three  and  and  a  half  inches  below  the  epi- 
trochlea,  and  carried  down  to  the  enveloping  fascia ;  the 
cutaneous  sleeve  is  dissected  up  for  about  an  inch,  and  the 
muscles  divided  transversely  at  its  base.  They  are  then 
retracted  forcibly  by  an  assistant  so  as  to  form  a  cone  with 
its  apex  directed  downward,  and  the  deep  muscles  of  the 
anterior  aspect  are  again  divided  transversely  on  a  level 
with  the  radio-humeral  articulation,  the  external  lateral 
ligament  being  included  in  the  incision  and  the  joint  there- 
by opened.  The  disarticulation  is  completed  as  before 
described. 

AMPUTATION   OF   THE   ARM. 

This  may  be  performed  at  any  poiut  below  the  attach- 
ments of  the  muscles  of  the  axilla.  Disarticulation  at  the 
shoulder  is  preferable  to  amputation  in  continuity  above 
these  attachments.  As  the  bone  is  centrally  placed  and 
well  covered  on  all  sides,  any  one  of  the  usual  methods  of 
amputation  may  be  employed.  As  a  general  rule  the  biceps 
should  be  divided  at  a  lower  level  than  the  other  muscles 
because  it  is  not  adherent  to  the  humerus,  and  therefore 
retracts  more  than  the  others.  The  circular  incision  should 
be  half  an  inch  lower  on  the  inner  thau  on  the  outer  side. 
In  muscular  subjects  flaps  should  be  cut  rather  thin,  and, 
when  possible,  it  is  better  that  the  main  artery  should  be 
in  the  posterior  flap. 


AMPUTATION    AT   THE    SHOULDER-JOINT. 

General  ( '<,nsi<leral.ionx.     The  exposed  position  and  great 
accessibility  of  the  head  of  the  humerus  have  led  to  the 


AMPUTATIONS.  81 

suggestion  of  many  operative  methods,  most  of  which  can 
be  performed  with  much  ease  and  regularity  upon  the  cada- 
ver, and  yield  good  results  in  actual  practice,  amputation 
at  the  shoulder-joint  being,  perhaps,  the  most  successful  of 
the  major  amputations.  But  as  the  operatiou  is  usually  ren- 
dered necessary  by  malignant  disease  or  compound  fracture 
of  the  humerus,  under  circumstances  which  make  it  very 
difficult,  if  not  impossible,  to  follow  regular  methods,  it  is 
more  important  to  be  familiar  with  the  anatomy  of  the 
parts  and  the  general  principles  governing  all  the  methods 
than  with  the  details  of  the  different  ones. 

The  size  of  the  axillary  artery  and  the  difficulty  of  effi- 
ciently compressing  the  subclavian  make  the  management 
of  the  artery  au  element  of  prime  importance  in  this  opera- 
tion. The  joint  should  be  approached  from  the  outer  side, 
and  the  artery  divided  from  within  outward  after  disarticu- 
lation, an  assistant  passing  his  thumb  into  the  wound  above 
the  knife  aud  compressing  the  vessel  before  it  has  been  cut. 
Or  the  artery  may  be  exposed  during  the  operation  and  tied 
before  it  is  cut. 

Pressure  upon  the  subclavian  may  be  made  by  the  thumb 
of  au  assistant  standing  behind  the  patient,  or  by  the  well- 
padded  handle  of  a  door  key  or  tourniquet,  or  a  rubber  tube 
or  cord  tightly  encircling  the  axilla,  scapula,  and  clavicle. 
To  prevent  slipping  of  the  cord  a  long  mattress-needle  is 
sometimes  introduced  near  the  tip  of  the  coracoid  process, 
carried  through  the  capsule  of  the  joint,  grazing  the  head 
of  the  humerus,  and  made  to  emerge  posteriorly  near  the 
axillary  border  of  the  scapula.  The  cord  is  then  applied 
circularly  on  the  proximal  side  of  the  skewer. 

Wyeth1  applies  an  Esmarch  rubber  baudage  from  the 
fiugers  to  the  axilla,  and  then  passes  a  skewer  through  the 
anterior  axillary  fold,  piercing  the  tendon  of  the  pectoralis 
major  from  above  down,  and  another  skewer  from  before 
backward  just  below  the  acromion  process  through  the  fibres 
of  the  deltoid.  After  placing  the  rubber  cord  on  the  prox- 
imal side  of  the  skewers  the  Esmarch  baudage  is  removed. 

The  subsequent  retraction  of  the  pectoralis  major  and 
latissimus  dorsi  leads  to  gaping  of  the  wound  aud  the  for- 

1  Joum.  Am.  Med.  Assoc  ,  February  7,  1891. 


82  OPERATIVE  SURGERY. 

raatiou  of  a  broad,  unsightly,  triangular  cicatrix.  This 
must  be  met  by  retaining  all  the  skin  for  the  first  two  or 
three  inches  in  the  flaps,  not  allowing  the  incisions  to  diverge 
from  one  another  until  the  end  of  the  flap  is  nearly  reached. 
This  precaution  also  insures  ample  covering  for  the  projec- 
ing  acromion.  The  outer  flap  should  comprise  the  entire 
thickness  of  the  deltoid  so  that  the  gap  left  by  the  head  of 
the  humerus  may  be  properly  filled,  and  it  should  be  dis- 
sected up  close  to  the  bone  so  as  to  avoid  injury  to  the  trunk 
of  the  posterior  circumflex  artery. 

Iustead  of  attempting  to  separate  the  capsule  at  its  at- 
tachment to  the  upper  edge  of  the  glenoid  cavity  by  pass- 
ing the  point  of  the  knife  under  the  acromion,  it  is  better 
to  divide  it  near  its  centre  by  drawing  the  edge  of  the  knife 
across  the  upper  surface  of  the  head  of  the  humerus  ;  and 
in  all  incisions  beginning  between  the  acromion  and  cora- 
coid  process  the  point  of  the  knife  should  be  passed  directly 
down  to  the  humerus  so  as  to  divide  the  strong  fibrous  arch 
connecting  the  two  processes. 

Oval  Method  (Baron  Larrey).  (Fig.  34,  A.)  A  longi- 
tudinal incision  involving  all  the  tissues  down  to  the  bone 
is  made  on  the  outer  aspect  of  the  shoulder  from  the  edge 
of  the  acromion  to  a  point  one  inch  below  the  neck  of  the 
humerus,  and  an  oval  one  interesting  the  skin  only  is  then 
carried  from  its  lower  end  aiound  the  arm,  crossing  its  inner 
side  about  an  inch  below  the  border  of  the  axilla.  The 
flaps  thus  marked  out  are  dissected  up,  the  anterior  one 
carefully,  until  the  tendon  of  the  pectoralis  major  is  ex- 
posed, and  divided  close  to  its  insertion,  the  posterior  one 
more  boldly,  but  close  to  the  bone,  so  as  to  avoid  injury  to 
the  trunk  of  the  circumflex  artery.  The  capsule  is  freely 
divided  across  the  head  of  the  humerus,  the  arm  rotated 
inward  and  then  outward  so  as  to  facilitate  the  division  of 
the  tendons  of  the  articular  muscles,  which  is  best  accom- 
plished by  cutting  directly  upon  the  tuberosities,  the  hume- 
rus thus  liberated  is  thrown  outward  by  adducting  the 
elbow,  the  knife  is  passed  behind  it  and  carried  down  and 
out  through  the  cutaneous  incision  on  the  inner  side,  while 
an  assistant  compresses  the  artery  in  the  wound. 

The  resulting  wound  is  comparatively  small,  allows  free 


AMPU1ATI0NS. 


83 


drainage  at  its  lower  angle,  is  likely  to  unite  by  first  inten- 
tion in  its  upper  half,  and  usually  leaves  a  linear  cicatrix. 

After  cutting  through  the  tendon  of  the  pectoralis  major, 
Verneuil  isolates  the  biceps  and  coraco-brachialis  with  his 
fingers,  divides  them,  seeks  for  the  artery,  and  ties  it  rather 
high  up  before  continuing  the  operation. 


Fig.  34. 


Disarticulation  at  the  shoulder. 
A.  Oval  method.    B.  Method  by  double  flaps. 


It  is  sometimes  not  easy  to  reach  and  divide  the  broad 
tendon  of  the  subscapulars ;  and  when  the  humerus  is 
broken  it  is,  of  course,  impossible  to  use  it  as  a  lever  to 
force  the  head  of  the  bone  out  of  the  socket,  and  this  part 
of  the  operation  may  thereby  be  rendered  somewhat  diffi- 
cult. These  and  the  hemorrhage  from  the  branches  of  the 
posterior  circumflex  are  the  principal  objections  to  this 
method,  which  has,  nevertheless,  yielded  excellent  results. 

The  articulation  is  uncovered  more  freely  by  any  of  the 
double  flap  methods  in  which  an  external  flap  is  fashioned 
out  of  the  deltoid  muscle.  Of  these  the  Lisfranc  method 
may  be  taken  as  the  type,  premising  only  that  while  the 
opening  of  the  articulation  by  transfixion  is  very  easy  of 
execution  upon  the  cadaver,  it  is  sometimes  impossible  upon 
the  living  subject,  and  inapplicable  to  cases  of  malignant 


8 4  OPERA  TI VE  S  URGER Y. 

disease  of  the  humerus.     Under  such  circumstances  the 
flaps  must  be  made  by  dissection  from  without  inward. 

Double  Flap  Method  (Lisfranc).  (Fig.  34,  B.)  Right 
shoulder.  While  the  arm  is  abducted  the  surgeon  enters 
the  point  of  a  two-edged  amputating  knife  at  the  outer  side 
of  the  coracoid  process,  carries  it  across  the  outer  aspect  of 
the  head  of  the  humerus,  and  brings  it  out  a  little  below  the 
posterior  border  of  the  acromion.  He  then  raises  the  fibres 
of  the  deltoid  with  his  left  hand,  works  the  knife  down- 
ward around  the  head  of  the  bone,  and  cuts  a  broad  flap 
about  five  inches  long.  In  this  manoeuvre  the  joint  should 
be  opened  at  its  upper  part,  the  tendons  of  the  supra-spina- 
tus  and  long  head  of  the  biceps  entirely  divided,  and  those 
of  the  subscapularis  and  infra-spinatus  partly  divided. 
The  arm  is  then  adducted,  the  knife  passed  through  the 
joint  to  the  inner  side,  and  a  long  inner  flap  cut  from  within 
outward. 

Left  shoulder.  The  knife  is  passed  in  the  opposite  direc- 
tion, that  is,  from  below  the  acromion  behind  to  the  coracoid 
process  in  front,  and  the  operation  completed  as  on  the 
right  side. 

Spence's  Method.  Prof.  S pence  has  introduced  a  method, 
for  which  he  claims  the  following  advantages  :  1st.  The 
better  form  of  the  stump.  2d.  The  division  of  the  pos- 
terior circumflex  artery  only  in  its  terminal  branches  in 
front.  3d.  The  great  ease  with  which  disarticulation  can 
be  accomplished.  Another  advantage  is  that  an  operation 
for  excision  of  the  head  of  the  humerus  can  be  easily  trans- 
formed into  a  disarticulation  by  its  means,  should  that  be 
found  necessary. 

He  describes  the  operation  as  follows  (Fig.  35) :'  "  The 
arm  being  slightly  abducted,  and  the  humerus  rotated  out- 
ward, I  cut  down  upon  the  head  of  the  humerus  imme- 
diately external  to  the  coracoid  process,  and  carry  the  in- 
cision down  through  the  clavicular  fibres  of  the  deltoid  and 
pectoralis  major  muscles,  till  I  reach  the  humeral  attach- 
ment of  the  latter  muscle,  which  I  divide.     I  then,  with  a 

"  Lectures  on  Surgery,  2d  <•<!.,  vol.  ii.  p. 662.     Ivlin.,  1876. 


AMPUTATIONS. 


85 


Fig.  35. 


gentle  curve,  carry  my  incision  across  and  fairly  through 
the  lower  fibres  of  the  deltoid  toward,  but  through,  the 
posterior  border  of  the  axilla.  Unless  the  textures  be 
much  torn,  I  next  mark  out  the  line 
of  the  lower  part  of  the  inner  sec- 
tion by  carrying  an  incision  through 
the  skin  and  fat  only,  from  the  point 
where  my  straight  incision  terminated, 
across  the  inside  of  the  arm  to  meet 
the  incision  at  the  outer  part.  If  the 
fibres  of  the  deltoid  have  been  thor- 
oughly divided,  the  flap,  together  with 
the  posterior  circumflex  artery,  can  be 
easily  separated  by  the  point  of  the 
finger  from  the  bone  and  joint,  and 
drawn  upward  and  backward  so  as  to 
expose  the  head  and  tuberosities  with- 
out further  use  of  the  knife.  The 
tendinous  insertions  of  the  capsular 
muscles,  the  long  head  of  the  biceps, 
and  the  capsule  are  next  divided  by 
cutting  directly  on  the  bone.  Disar- 
ticulation is  then  accomplished,  and 
the  limb  removed  by  dividing  the  remaining  soft  parts  on 
the  axillary  aspect. 

"  In  cases  where  the  limb  is  very  muscular  I  dissect  the 
skin  and  fat  from  the  deltoid  at  the  lower  part,  and  then 
divide  the  muscular  fibres  higher  up  by  a  second  incision, 
so  as  to  avoid  redundancy  of  muscular  tissue." 


Disarticulation  at 
the  shoulder. 
Spence's  method. 


AMPUTATION     OF     THE     ARM,    SCAPULA,    AND     PAET    OR 
ALL   OF   THE    CLAVICLE. 


Make  an  incisiou  along  the  ureter  two-thirds  of  the  front 
of  the  clavicle;  carry  the  incision  through  the  periosteum. 
Divide  the  periosteum  transversely  at  the  inner  angle  of 
the  wound  and  strip  it  as  far  as  possible  from  the  middle 
third  of  the  bone.  Then  pass  a  periosteal  elevator  or  blunt 
hook  beneath  the  clavicle  at  the  inner  angle  of  the  wound 
to  protect  the  underlying  parts,  and  saw  through  the  bone 

5 


86  OPERATIVE  SURGERY. 

at  this  point.  Raise  the  sawn  end  of  the  outer  fragment, 
strip  off  the  periosteum  from  its  deeper  surface,  and  saw  it 
through  again  at  about  the  junction  of  the  outer  and  mid- 
dle thirds.  Through  the  gap  thus  made  the  great  vessels 
are  exposed  and  divided  between  separate  double  ligatures 
for  each,  close  to  the  first  rib. 

Fig.  36. 


0 


/•' 


Amputation  of  the  arm,  scapula,  and  part  or  all  of  tbe  clavicle.  (The  dotted 
lines  represent  the  part  of  the  incision  which  lies  on  the  posterior  aspect  of  the 
body.)    (Treves.) 

A  second  incision  is  made  from  the  centre  of  the  first 
downward  and  outward,  along  the  groove  between  the 
pectoral  and  deltoid  muscles,  to  the  junction  of  the  anterior 
axillary  fold  with  the  arm.  Thence  across  the  inner  sur- 
face of  the  arm  to  the  junction  of  the  posterior  axillary 
fold  with  the  arm,  dividing  at  this  point  the  tendons  of  the 
teres  major  and  latissimus  dorsi  ;  thence  the  incision  is  car- 
ried downward  and  inward  between  the  teres  major  and 
latissimus  dorsi  to  the  inferior  angle  of  the  scapula. 

The  skin  and  subcutaneous  tissue  over  the  anterior  fold 
of  the  axilla  is  raised,  and  the  pectoralis  major  cut  where 
it  begins  to  become  tendinous. 

The  pectoralis  minor  is  severed  close  to  thecoracoid  pro- 
cess, and  after  division  of  the  cords  of  the  brachial  plexus 
at  the  level  where  the  great  vessels  were  cut,  only  the  mus- 
cles attached   to  the   trunk  and  scapula  retain  the  limb. 


AMPUTATIONS. 


87 


The  patient  is  then  turned  toward  the  opposite  side. 
Another  incision,  through  the  skin  and  subcutaneous  tis- 
sue, is  carried  from  the  outer  end  of  the  first  clavicular 
iucision  at  the  acromioclavicular  joint,  across  the  spine  of 
the  scapula  to  terminate  iu  the  second  incision  at  the  in- 
ferior angle  of  the  scapula.  The  skin  and  subcutaneous 
tissue  on  the  inner  side  of  the  incision  are  raised  sufficiently 
to  permit  division  of  the  clavicular  and  scapular  attach- 
ments of  the  trapezius. 

Then,  starting  at  the  outer  end  of  the  superior  border  of 
the  scapula,  the  omohyoid,  levator  anguli  scapulas,  rhom- 
boideus  minor  and  major,  and  the  serratus  magnus  are 
divided  in  this  order  close  to  the  bone,  and  the  limb  de- 
tached. 

The  early  ligation  of  the  subclavian  vessels  prevents  any 
great  loss  of  blood.  The  sutured  wound  forms  an  oblique 
line  running  from  above  downward,  outward,  and  backward. 


Fig.  37. 


AMPUTATION    OF   THE   TOES. 

The  different  phalanges  of  the  toes  may  be  removed  by 
the  same  methods,  and  at  the  same  points,  as  those  of  the 
fingers,  but  experience  has  shown  that,  except  for  the  great 
toe,  it  is  better  to  disarticulate  at  the 
metatarso-pharyngeal  joint,  the  pre- 
servation of  a  portion  of  a  toe  being 
a  source  of  discomfort  rather  than  an 
advantage.  In  the  case  of  the  great 
toe  it  is  desirable  to  save  as  much  as 
possible,  and  amputation  in  continuity 
is  to  be  preferred  to  disarticulation. 
In  all  operations  upon  the  foot  the  in- 
cisions should  be  so  arranged  that  the 
cicatrices  will  not  occupy  the  plantar 
surface.  It  must  be  remembered  that 
the  web  between  the  toes  lies  far 
below  the  metatarsophalangeal  joint. 
(Fig.  37.)  m 

The  incision  should  be  commenced 
on  the  dorsal  surface  a  little  above 
the  joint,  carried  directly  clown  the  bone  for  about  an  inch, 
and  then,  diverging  abruptly,  into  the  web,  straight  across 


Relations  of  the  web 
and  metatarso-plialangeal 
joint. 


88 


OPERATIVE  SURGERY 


in  the  digitoplantar  fold,  and  back  on  the  other  side  to  the 
point  of  divergence  (Fig.  38,  A).  If  the  strong  flexor  ten- 
dons have  been  completely  divided  it  will  then  be  found 
easy  to  disarticulate  by  entering  the  knife  at  the  side  of  the 
joint.  This  oval  incision  is  better  than  the  two  lateral 
semilunar  flaps,  because  its  cicatrix  does  not  extend  into  the 
sole  of  the  foot. 


The  distal  phalanx  of  the  great  toe  may  be  removed  ac- 
cording to  the  methods  described  for  the  corresponding 
part  of  the  thumb  and  fingers  (p.  72). 


Fig.  38. 


Fig.  39. 


—  1 


Amputation  of  the  great  toe. 

Disarticulation  of  the  great  toe 
at  the  metatarsophalangeal  joint 
may  be  done  according  to  the 
method  just  described  for  the  other 
toes,  or  with  a  large  internal  flap. 
In  the  latter  case  an  incision  (Fig. 
39,  A)  is  begun  on  the  outer  side 
of  the  extensor  tendon  just  below 
the  joint,  and  carried  straight 
down  to  the  head  of  the  first 
phalanx.  From  its  lower  end 
a  transverse  incision  is  carried 
around  the  inner  side  of  the  toe 
to  the  outer  edge  of  the  flexor  ten- 
don, and,  the  toe  being  then  for- 
cibly extended,  a  plantar  excision 
is  carried  from  the  end  of  the  transverse  incision  (Fig. 
39,  B),  along  the  outer  side  of  the  flexor  tendon  to  the 
digito-plantar    fold,  and  thence  transversely  around  the 


Amputation  of  the  toes   and 
metatarsal  bones. 


AMP  VTA  TIONS.  8  9 

outer  side  of  the  toe  to  rejoin  the  first  incision  near  its 
centre. 

The  internal  flap  is  then  dissected  from  below  upward, 
the  extensor  tendon  divided  high  up,  the  lateral  ligaments 
divided,  the  knife  passed  through  the  joint,  and  the  remain- 
ing soft  parts  cut  from  within  outward. 

The  same  incisions  made  somewhat  lower  down  may  be 
used  for  amputation  in  continuity,  but  usually  the  shape 
and  position  of  the  flaps  will  be  determined  by  the  nature 
and  extent  of  the  injury  which  makes  the  operation  neces- 
sary. 

Amputation  of  two  adjoining  Toes.  The  dorsal  incision 
should  begin  in  the  intermetatarsal  space  just  above  the 
level  of  the  joint  (Fig.  38,  B),  extend  down  to  the  begin- 
ning of  the  web,  diverge  obliquely  to  the  adjoining  web, 
cross  the  plantar  surface  in  the  digito-plantar  fold  of  both 
toes,  and  return  through  the  other  adjoining  web  to  the 
point  of  divergence.  Each  toe  is  then  removed  separately 
after  division  of  its  tendons  and  lateral  ligaments. 

AMPUTATION    OF   A   METATARSAL   BONE. 

Amputation  in  continuity  is  much  to  be  preferred  to  dis- 
articulation on  account  of  the  extent  of  some  of  the  syno- 
vial sacs,  the  attachments  of  certain  muscles,  and  the  im- 
portance of  some  of  the  bones  in  preserving  the  relations 
of  the  others.  The  synovial  sac  which  forms  part  of  the 
articulation  between  the  first  cuneiform  and  first  metatarsal 
bones  is  isolated  from  the  others,  but  the  attachment  of  the 
peroneus  longus  to  the  base  of  the  latter  bone  renders  its 
preservation  especially  important.  There  is  also  a  separate 
synovial  sac  for  the  articulation  between  the  cuboid  and  the 
fourth  and  fifth  metatarsals.  The  base  of  the  fifth  meta- 
tarsal is  easily  recognized  by  the  prominence  which  it  forms 
on  the  outer  side  of  the  foot ;  that  of  the  first  metatarsal  is 
three-fourths  of  an  inch  anterior  to  the  other,  and  is  the  first 
prominence  encountered  by  the  finger  when  it  is  passed  from 
before  backward  along  the  inner  side  of  the  bone. 

The  incision  begins  on  the  dorsal  aspect  at,  or  a  little  be- 
low, the  point  at  which  the  bone  is  to  be  divided,  is  carried 


90  OPERATIVE  SURGERY. 

down  well  below  the  nietatarso-phalangeal  joint  (Fig.  38, 
C),  diverges  into  the  web,  crosses  the  plantar  surface  in 
the  digito-plantar  fold,  and  returns  through  the  other  web 
to  the  point  of  divergence.  A  short  transverse  incision  is 
made  through  the  skin  at  its  upper  end  to  facilitate  division 
of  the  bone,  which  is  then  effected  with  cutting  pliers  or  a 
chain  saw  after  the  soft  parts  have  been  separated  on  both 
sides.  The  toe  is  then  pressed  backward,  the  cut  end  of 
the  bone  raised,  the  knife  passed  behind  it,  and  the  opera- 
tion completed  by  cutting  from  within  outward.  The  first 
and  fifth  metacarpal  bones  should  be  cut  obliquely  so  as  to 
diminish  the  prominence  of  the  stump. 

For  disarticulation  of  the  first  or  fifth  metetarsal  bones 
the  only  modification  needed  is  to  begin  the  incision  at  a 
correspondingly  higher  point — at  or  a  little  below  the  tarso- 
metatarsal joint  (Fig.  38,  D).  After  the  flaps  have  been 
dissected  up,  the  joint  is  opened  by  dividing  the  dorsal  and 
interosseous  ligaments,  and  the  bone  raised  and  separated 
from  the  remaining  soft  parts. 


DISARTICULATION  OF  ALL  THE  METATARSAL  BONES. 
(TARSO-METATARSAL  DISARTICULATION  ;  LISFRANC'S 
OR   hey's   AMPUTATION.) 

The  position  and  general  direction  of  the  tarso-metatarsal 
articulations,  as  well  as  the  peculiarity  presented  by  the 
base  of  the  second  metatarsal  bone,  are  sufficiently  well 
shown  in  Fig.  40  to  render  a  detailed  description  unneces- 
sary. The  guides  to  the  articulation  are  the  projecting 
bases  of  the  first  and  fifth  metatarsal  bones. 

The  skin  being  retracted  by  an  assistant,  the  surgeon 
makes  with  a  scalpel  a  curved  incision  across  the  dorsum  of 
the  foot  from  the  base  of  the  fifth  to  the  base  of  the  first 
metatarsal  bone.  (For  the  left  foot  the  direction  of  this 
incision  must  be  reversed.)  The  incision  should  involve 
the  skin  only,  its  centre  should  lie  half  an  inch  or  more 
below  the  centre  of  the  line  of  the  articulations,  and  it 
should  begin  and  end  upon  the  sides  of  the  foot  at  their 
junction  with  the  sole.     (I-^ig.  40.) 


AMPUTATIONS. 


91 


Fig.  40. 


A  plantar  flap  should  then  be  marked  out  by  a  curved 
incision  beginning  and  endiug  at  the  same  points  as  the  first 
aud  crossing  the  sole  near  the  origin  of  the  toes.  The  dor- 
sal skin  flap  is  then  dissected  back  to  the  line  of  the  articu- 
lation, the  tendons  aud  muscular  fibres  of  the  short  extensor 
divided,  the  joints  between  the  fifth,  fourth,  and  third  meta- 
tarsals, and  the  corresponding  bones  of  the  tarsus  opened 
successively  from  the  outer  side,  aud  that  between  the  first 
metatarsal  aud  first  cuneiform  from  the  inner  side.  With 
the  point  of  the  knife  directed  transversely  across  the  dorsal 
aspect  of  the  base  of  the  second  me- 
tatarsal, thejoint  between  that  bone 
and  the  second  cuneiform  is  sought 
from  below  upward,  aud  after  it 
has  been  found  aud  opened  the  in- 
terosseous ligaments  uniting  the 
second  to  the  first  and  third  meta- 
tarsals are  divided  by  thrusting 
the  point  of  the  knife  well  down 
between  them,  the  flat  of  its  blade 
being  held  parallel  to  the  long  axis 
of  the  foot,  and  the  toes  being  forc- 
ibly depressed. 

After  the  bone  has  been  thus  dis- 
engaged, the  knife  is  passed  through 
the  articulation,  and  the  plantar  flap 
cut  from  within  outward. 

Modifications.  The  plantar  flap 
may  be  cut  (1)  from  without  in- 
ward, or  (2)  by  transfixion,  before 
the  articulations  have  been  opened. 
J  nstead  of  disarticulating  it,  thebase 
of  the  second  metatarsal  may  be  cut 
off  with  pliers  or  a  saw  and  left  in 
place.  Hey  sawed  off  the  projecting 
part  of  the  first  cuneiform  after  dis- 
articulating, but  this  weakens  the  attachment  of  the  tibialis 
anticus,  a  disadvantage  which  is  not  offset  by  the  improve- 
ment in  the  outline. 


A.  Lisfranc's  amputation. 

B.  Chopart's  amputation. 


92 


OPERATIVE  SURGERY. 


MEDIO-TARSAL    OR   CHOPART  S    AMPUTATION. 

This  name  is  given  to  the  operation  of  disarticulation 
through  the  joints  formed  by  the  astragalus  and  calcaneum 
behind,  the  scaphoid  and  cuboid  in  front.  The  guides  to 
the  joint  are  the  tubercle  of  the  scaphoid  on  the  inner  side 
of  the  foot,  the  head  of  the  astragalus  on  the  dorsum,  and  the 
anterior  end  of  the  calcaneum  on  the  outer  border.  The  first 
named  is  one-eighth  of  an  inch  in  front  of  the  articulation, 
and  is  the  first  bony  prominence  found  on  drawing  the  finger 
from  the  inner  malleolus  forward  along  the  side  of  the  foot ; 
the  sharp  edge  of  the  second  can  be  readily  felt  when  the  an- 
terior portion  of  the  foot  is  forcibly  depressed ;  the  latter  can 
usually  be  made  out  by  adducting  the  toes  and  invertiug  the 
sole,  nearly  midway  between  the  tip  of  the  external  mal- 
leolus and  the  base  of  the  fifth  metatarsal  bone,  or  nearer 
the  latter.  When  the  foot  is  at  right  angles  with  the  leg, 
the  anterior  articular  surfaces  of  the  astragalus  and  cal- 
caneum are  in  the  same  plane,  one  crossing  the  foot  trans- 
versely at  the  points  indicated. 


Fig.  41. 


Outer  side.    A.  Choparl's  amputation,    B.  Byrne's  amputation.    C.  Subastraga- 
loid  amputation.    D.  Line  of  section  of  the  bones  in  Syme's  amputation. 

Operation.     (Figs.  40,  41,  42.)    The  surgeon  places  the 
thumb  and  forefinger  of  his  left  hand  upon  the  tubercle  of 


AMPUTATIONS.  93 

the  scaphoid  and  the  lower  and  outer  border  of  the  cuboid, 
with  the  palm  against  the  sole,  and  makes  a  curved  incision 
from  one  to  the  other,  passing  an  inch  anterior  to  the  head 
of  the  astragalus,  and  terminating  on  each  side  just  below 
the  level  of  the  joint.  The  plantar  flap  is  next  marked  out 
by  an  incision  beginning  and  ending  at  the  same  points  as 
the  first,  and  crossing  the  sole  of  the  foot  four  or  five  finger- 
breadths  nearer  the  toes.  The  dorsal  flap  is  next  dissected 
up,  the  joint  entered  at  either  of  the  points  mentioned  as 
guides  (preferably  between  the  astragalus  and  scaphoid  on 
the  inner  side,  after  dividing  the  tendons  of  the  tibiales), 
opened  widely  by  dividing  the  dorsal  and  interosseous  liga- 
ments and  depressing  the  toes,  and  the  plantar  flap  cut  from 
within  outward. 

Syme  preferred  to  make  the  plantar  flap  by  transfixion 
before  disarticulating. 

The  anterior  tendons  should  be  stitched  to  the  deep 
tissues,  and  the  dressing  should  keep  the  foot  in  extreme 
dorsal  flexion  at  the  ankle  in  order  that  these  tendons  may 
so  unite  with  the  stump  that  their  muscles  will  prevent  the 
heel  from  being  raised  by  the  unopposed  action  of  the  mus- 
cles of  the  calf. 

Tripiei^s  amputation  is  practically  a  modification  o± 
Chopart's.  Its  purpose  is  to  afford  a  broad  and  level 
basis  of  support  by  sawing  the  os  calcis  from  its  upper 
posterior  to  its  anterior  inferior  angle,  and  so  prevent  any 
raising  of  the  heel,  an  objectionable  feature  in  Chopart's 
operation.  The  incision  begins  at  the  outer  edge  of  the 
tendo  Achillis  on  a  line  with  the  tip  of  the  external  mal- 
leolus, passes  forward  about  an  inch  below  the  latter  to  a 
point  a  finger's-breadth  behind  the  base  of  the  fifth  meta- 
tarsal, thence  across  the  dorsum  of  the  foot  with  a  gentle 
curve  to  the  extensor  proprius  hallucis  tendon  over  the 
astragalo- scaphoid  joint ;  thence  forward  on  the  superior 
surface  of  the  scaphoid  and  internal  cuneiform  to  near  the 
base  of  the  first  metatarsal.  From  this  point  it  curves 
around  the  inner  border  of  the  foot  and  across  the  sole  to 
its  outer  edge  at  the  base  of  the  fifth  metatarsal,  and  thence 
upward  and  backward  to  join  the  dorsal  incision.  The 
anterior   portion    of    the    foot   is   removed    through    the 

5* 


94 


OPERATIVE  SURGERY. 


astragalo  scaphoid  and  calcaneocuboid  joints,  the  soft 
parts  elevated  from  the  inferior  and  internal  surfaces  of 
the  os  calcis,  and  the  latter  sawn  through  horizontally  just 
below  the  sustentaculum  tali.  The  saw-cut  is  oblique  to 
the  long  axis  of  the  calcaneurn,  which  is  normally  elevated 
toward  the  front. 

SUB-ASTKAGALOID   AMPUTATION. 


(Figs.  41,  C,  and  42,  C.)  The  guides  to  this  operation 
are  the  tip  of  the  external  malleolus  and  the  head  of  the 
astragalus.    The  joint  must  be  entered  from  in  front  on  the 


Fig.  42. 


Inner  side.    A.  Chopart's  amputation.    B.  Syme's  amputation. 
C.  Subastragaloid  amputation. 

fibular  side,  and  the  strong  interosseous  ligament  which 
forms  the  key  to  the  articulation  must  be  divided  step  by 
st<|>  from  before  backward  and  inward.  The  posterior 
tibial  vessels  lie  behind  the  inner  malleolus,  and  must  be 
carefully  avoided. 

Beginning  at  the  outer  side  of  the  heel,  nearly  an  inch 
below  the  tip  of  the  external  malleolus,  an  incision,  extend- 
ing through  to  the  bone,  is  carried  straight  forward  to  the 
base  of  the  fifth  metatarsal  bone;  thence,  curving  forward, 
across  the  dorsum  of  the  foot  to  the  base  of  the  first  meta- 
tarsal ;  thence  obliquely  backward  and  outward  across  the 


AMPUTATIONS.  95 

sole  of  the  foot  and  around  its  outer  border,  rejoining  the 
first  and  horizontal  part  of  the  incision  at  the  calcaneo- 
cuboid articulation.  The  soft  parts  must  be  separated  from 
the  outer  surface  of  the  calcaneum  and  cuboid  with  division 
of  the  peroneal  tendons,  the  dorsal  flap  dissected  back  to 
the  head  of  the  astragalus,  and,  on  the  inner  side,  beyond 
the  tubercle  of  the  scaphoid,  thus  dividing  the  tendon  of 
the  tibialis  anticus  and  the  anterior  portiou  of  the  internal 
lateral  ligament.  The  interosseous  ligament  can  then  be 
easily  reached  by  depressing  the  toes,  passing  the  knife  be- 
tween the  astragalus  and  scaphoid,  and  cutting  backward 
and  inward  along  the  under  surface  of  the  former.  The 
soft  parts  on  the  inner  side  are  then  separated  from  the  cal- 
caneum, injury  to  the  vessels  being  avoided  by  keeping  close 
to  the  bone,  between  it  and  the  tendon  of  the  flexor  com- 
munis, the  foot  depressed,  and  the  tendo  Achillis  divided. 
This  last  is  a  very  difficult  part  of  the  operation,  and  great 
care  must  be  taken  to  keep  the  edge  of  the  knife  close  to 
the  bone,  so  as  not  to  cut  through  the  skin. 

The  posterior  tibial  nerve  should  be  dissected  out  and  cut 
off  as  high  up  as  possible,  so  that  it  shall  not  be  pressed 
upon  the  stump. 

Farabeuf  has  slightly  modified  this,  as  follows: 
The  incision  is  begun  at  the  outer  margin  of  the  tendo 
Achillis,  close  to  the  upper  border  of  the  os  calcis,  and  car- 
ried horizontally  forward  along  the  outer  side  of  the  latter 
bone,  passing  about  one  inch  below  the  external  malleous. 
At  the  base  of  the  fifth  metatarsal  it  turns  over  the  dorsum 
of  the  foot  to  the  base  of  the  first  metatarsal,  thence  across 
the  sole  to  its  outer  margin  opposite  the  base  of  the  fifth 
metatarsal.  From  this  point  it  passes  backward  along  the 
outer  edge  of  the  plantar  surface  of  the  foot  to  the  poste- 
rior external  tubercle  of  the  os  calcis,  whence  it  curves  up- 
ward to  the  starting-point  at  the  upper  and  back  part  of 
the  os  calcis  and  outer  border  of  the  tendo  Achillis. 

AMPUTATION    AT   THE    ANKLE-JOINT. 

Syme's  Amputation,  Tibio-tarsal  Amputation.  (Figs.  41, 
42,  J5.)     Amputation  through  the  ankle-joint  by  the  cir- 


96  OPERATIVE  SURGERY. 

cular  method,  lateral  flaps,  or  a  long  anterior  flap  taken 
from  the  dorsum  of  the  foot,  as  proposed  by  Baudens,  did 
not  meet  with  favor,  because  the  delicacy  of  the  coverings 
or  the  vicious  position  of  the  cicatrix  rendered  the  stump 
practically  useless;  and,  although  occasional  successes  were 
reported,  the  choice  still  lay  between  Chopart's  operation 
and  amputation  of  the  leg,  until  Prof.  Syme,  in  1843,1 
showed  how  the  excellent  plantar  flap  could  be  obtained. 
About  the  same  time  Jules  Roux,  of  Toulon,  met  the  same 
indication  by  means  of  a  large  internal  lateral  flap  carried 
across  the  plantar  aspect  of  the  heel. 

By  greatly  restricting  the  necessity  for  amputation  of  the 
leg  this  operation  has  become  one  of  the  most  important 
and  frequently  performed  of  all  amputations.  The  objec- 
tions urged  against  it,  and  the  unfavorable  results  that  have 
sometimes  followed  its  use,  seem  to  have  had  their  origin 
in  a  failure  to  understand  or  carry  out  all  the  details  of  its 
execution,  or  in  the  introduction  of  improper  modifications. 
It  has  seemed  desirable,  therefore,  to  reproduce  here  Prof. 
Syme's  directions  for  performing  it,  as  published  in  1848,2 
six  years  after  he  had  first  put  it  iuto  practice. 

"  Succeeding  experience  taught  me  that  a  much  smaller 
extent  of  flap  than  had  originally  been  considered  necessary 
was  sufficient  for  the  purpose,  and  that  hence  the  operation 
could  not  only  be  simplified  in  performance,  but  increased 
in  safety  from  bad  effects. 

"  The  foot  being  placed  at  a  right  angle  to  the  leg,  a  line 
drawn  from  the  centre  of  one  malleolus  to  that  of  the  other, 
directly  across  the  sole  of  the  foot,  will  show  the  proper 
extent  of  the  posterior  flap.  The  knife  should  be  entered 
close  up  to  the  fibular  malleolus,'5  and  carried  to  a  point  on 
the  same  level  of  the  opposite  side,  which  will  be  a  little 
below  the  tibial  malleolus.  The  anterior  incision  should 
join  the  two  points  just  mentioned  at  an  angle  of  45°  to  the 
sole  of  the  foot,  and  long  axis  of  the  leg.  In  dissecting  the 
posterior  flap,  the  operator  should  place  the  fingers  of  his 
left  hand  upon  the  heel,  while  the  thumb  rests  upon  the  edge 
of  the  integuments,  and  then  cut  between  the  nail  of  the 

1  Lond.  and  Edin.  Monthly  Journ.  of  Med.  Science,  Feb.  1843. 
-  Contributions  to  the  I'ath.  and  Practice  of  Surgery.    Edinburgh,  1848. 
•  "  The  lip  of  the  external  malleolus,  oralittle  posterior  to  it;  rather  nearer  the 
posterior  than  the  anterior  margin  of  the  bone." — Syme,  in  Lancet,  1855. 


AMPUTATIONS.  97 

thumb  and  tuberosity  of  the  os  calcis,  so  as  to  avoid  lacer- 
ating the  soft  parts,  which  he  at  the  same  time  gently,  but 
steadily,  presses  back  until  he  exposes  and  divides  the 
tendo  Achillis.1  The  foot  should  be  disarticulated  before 
the  malleolar  projections  are  removed,  which  it  is  always 
proper  to  do,  and  which  may  be  most  easily  effected  by 
passing  a  knife  round  the  exposed  extremities  of  the  bones 
and  then  sawing  off  a  thin  slice  of  the  tibia  connecting  the 
two  processes." 

Disarticulation  is  accomplished  by  opening  the  joint  in 
front  and  dividing  the  lateral  ligaments  by  entering  the 
point  of  the  knife  between  the  sides  of  the  astragalus  and 
the  malleoli. 

The  essentials  of  the  method,  as  pointed  out  by  the  more 
recent  Scotch  writers  (Lister,  Spence,  and  Bell),  are  that 
the  plantar  incision  should  run  from  the  tip  of  the  external 
malleolus  directly  across  the  heel,  should  on  no  account  in- 
cline forward,  and  should  terminate  at  least  half  an  inch 
below  the  tip  of  the  internal  malleolus  (behind  and  below, 
according  to  Lister).  In  case  the  heel  is  unusually  long 
the  incision  may  even  incline  backward.  It  is  not  only 
unnecessary,  but  actually  dangerous,  to  make  the  flap  longer 
than  this,  for  it  then  becomes  impossible  to  dissect  out  the 
calcaneum  without  scoring  the  subcutaneous  tissue  in  all 
directions,  and  increasing  the  chances  of  sloughing.  If  the 
incision  is  made  further  back  and  carried  any  higher  on  the 
inner  side,  the  posterior  tibial  will  be  cut  before  its  division 
into  the  two  plantar  arteries. 

Erichsen  and  Lister  both  claim  that  the  integrity  of  the 
posterior  tibial  is  not  of  great  importance,  the  vitality  of 
the  flap  depending  mainly  upon  anastomosing  branches  of 
high  origin  which  lie  quite  near  the  bone.  Erichsen2  calls 
attention  to  the  existence  of  a  "  branch  of  considerable 
size  which  arises  from  the  posterior  tibial  artery,  about  one 
and  a  half  to  two  inches  above  the  ankle-joint,  and  passes 
down  to  the  inner  side  of  the  os  calcis,"  communicating 
freely  above,  below,  and  behind  this  bone  with  the  peroneal 
artery  on  the  other  side.     As  these  anastomosing  loops  lie 

1  It  is  now  generally  considered  better  to  divide  the  tendon  from  above  down- 
ward, after  disarticulating,  keeping  the  edge  of  the  knife  close  to  the  upper  and 
posterior  aspect  of  the  bone. 

2  Science  and  Art  of  Surgery,  vol.  i.  p.  77.    Lea,  Phila.,  1873. 


98  OPERATIVE  SURGERY. 

much  nearer  the  bone  than  the  skin,  great  numbers  of  them 
will  be  divided,  and  the  vitality  of  the  flap  endangered, 
unless  the  edge  of  the  knife  is  kept  close  against  the  bone 
during  the  dissection.  Lister  goes  so  far  as  to  say  that 
sloughing  of  the  flap  is  always  the  fault  of  the  surgeon, 
and  Bell  intimates  the  same  thing. 

Roux1  has  shown  that  this  close  dissection  is  not  without 
its  dangers  from  the  other  side.  In  two  of  his  cases  osteo- 
phytes developed  within  the  stump  from  portions  of  the 
periosteum  left  adherent  to  the  flap.  The  autopsy  in  one 
of  these  cases  showed  that  six  osteophytes  had  formed  and 
become  carious  within  a  year  after  the  operation. 

A  short  longitudinal  iucision  through  the  deep  parts 
along  the  middle  of  the  plantar  aspect  of  the  calcaneum 
will  sometimes  render  this  step  of  the  operation  easier,  and 
be  less  disadvantageous  than  the  employment  of  great  force. 

Modifications.  A.  Internal  Lateral  Flap.  When 
the  outer  side  of  the  foot  has  been  so  altered  by  injury  or 
disease  that  the  heel  flap  cannot  be  obtained,  a  very  good 
substitute  may  be  had  in  the  large  internal  flap  suggested 
by  Jules  Roux,  aud  adopted  with  slight  changes  by  Sedil- 
lot,  Mackenzie,  and  others.  Prof.  Spence  says  this  stump 
can  hardly  be  distinguished  from  Syme's. 

An  iucision  (Fig.  43)  is  commenced  at  the  outer  side  of 
the  tendo  Achillis,  a  little  above  its  insertion,  carried  straight 
forward  under  the  outer  malleolus,  then  in  a  curved  line 
across  the  instep  half  an  inch  in  front  of  the  anterior  articu- 
lar edge  of  the  tibia,  and  backward  to  a  point  just  in  front 
of  the  inner  malleolus;  thence  directly  downward  to  the 
sole,  across  it  obliquely  backward  to  its  outer  border,  and 
then  backward  and  upward  around  the  heel  to  the  point  at 
which  it  began.  The  edges  of  the  flaps  are  next  dissected 
up  for  a  short  distance,  the  joint  entered  at  the  outer  side, 
and  the  internal  flap  completed  from  within  outward  after 
disarticulation. 

Sedillot's  modification  of  this  consists  in  making  the  flap 
more  quadrilateral  than  triangular,  by  a  semicircular  incision 
across  the  dorsum  three  finger-breadths  in  front  of  the  mal- 

1  Hull,  de  la  Soc.  <le  Ohirurgie,  torn.  iii.  p.  491,  1853. 


AMPUTATIONS. 


99 


leoli,  and  by  carrying  the  posterior  end  of  the  external  hori- 
zontal incision  across  the  tendo  Achillis  to  its  inner  border. 

Mackenzie's  method  differs  only  in  beginning  the  incision 
at  the  inner  border  of  the  tendon  and  a  little  higher  up. 

It  is  probable  that  a  serviceable  external  flap  could  be 
made  in  the  same  way,  although  its  vascular  supply  would 
be  scantier. 

B.  Pirogoff's  Amputation.  This  is  a  much  more  im- 
portant modification,  since  it  involves  not  merely  the  method 
of  performing  the  operation,  but  also  the  retention  of  the 
posterior  portion  of  the  calcanemn,  and  its  ultimate  union 

Fig.  43. 


Amputation  through  the  ankle-joint  by  large  internal  lateral  flap.    (Roux. 


with  the  tibia.  The  only  additional  anatomical  point  that 
needs  mention  in  connection  with  it  is  that  the  long  axis  of 
the  calcaneum  is  directed  upward  as  well  as  forward. 

An  incision  (Figs.  44  and  45,  A)  is  made  from  the  tip 
of  the  inner  malleolus  to  a  point  a  little  above  and  in  front 
of  the  tip  of  the  outer  malleolus,  crossing  the  instep  half 
an  inch  in  front  of  the  anterior  edge  of  the  tibia.  A  second 
incision  crossing  the  sole  at  the  level  of  the  calcaneo-cuboid 
articulation  unites  the  extremities  of  the  first,  and  should  be 
carried  boldly  down  to  the  bone.  The  plantar  flap  is  then 
dissected  back  for  a  quarter  of  an  inch,  and  the  dorsal  flap 
to  the  edge  of  the  joint,  the  malleoli  well  exposed,  and 


100 


OPERA TIVE  SURGE R  Y. 


the  joint  opened  widely  by  dividing  the  lateral  ligaments. 
By  drawing  the  foot  forward  and  depressing  it  a  narrow 
butcher's  or  a  chain  saw  can  be  passed  through  the  joint, 


Fig.  44. 


Pirogofi 's  amputation.    A.  Cutaneous  incision  (outer  side).    B.  Line  of  section 
of  the  bones. 

Fig.  45. 


PirogolPs  amputation.    A.  Cutaneous  incision  (inner  side).    B.  Parallel  section 
of  the  bones  (Sudillot's  modification). 


and  applied  to  the  calcancum  behind  the  posterior  lip  of  the 
astragalus,  and  the  bone  sawn  through  downward  and  for- 
ward in  such  a  direction  that  the  section  will  terminate 


AMPUTATIONS.  101 

half  an  inch  behind  the  lower  edge  of  the  calcaneo-cuboid 
articulation.  The  malleoli  and  a  slice  of  the  tibia  are 
then  removed  as  in  Syme's  operation,  and  enough  of  the 
anterior  angle  of  the  calcaneum  removed  to  make  the  length 
of  its  surface  of  section  correspond  with  that  of  the  tibia. 
Some  surgeons  prefer  to  reverse  this  order,  and  remove  the 
malleoli  before  sawing  through  the  calcaneum.1 

The  cut  surface  of  the  calcaneum  must  then  be  brought 
up  against  that  of  the  tibia,  and  if  the  section  of  the  former 
has  been  sufficiently  oblique,  and  has  commenced  far  enough 
back,  this  can  be  done  without  making  excessive  tension 
upon  the  tendo  Achillis,  otherwise  another  slice  must  be 
removed  from  one  of  the  bones  or  the  tendon  divided  sub- 
cutaneously.  Suturing  together  of  the  bones  has  been  occa- 
sionally tried,  as  has  also  fastening  them  together  by  a  long 
steel  pin  driven  through  the  skin  of  the  sole  and  the  cal- 
caneum into  the  tibia. 

Several  modifications  of  this  operation  have  been  sug- 
gested, but  they  can  hardly  be  considered  as  improvements. 
Vertical  division  of  the  calcaneum,  as  originally  proposed 
by  Pirogoff  and  Ure,2  deprives  the  stump  of  the  advantages 
of  the  heel  pad  by  swinging  the  latter  too  far  forward,  and 
bringing  the  weight  of  the  body  upon  the  thinner  skin  cover- 
ing the  insertion  of  the  tendo  Achillis.  It  also  causes  undue 
tension  of  the  tendon  when  the  bones  are  brought  together. 
S6dillot  suggested  an  oblique  section  of  the  tibia  upward 
and  backward,  parallel  to  that  of  the  calcaneum  (Fig.  45, 
B).  This  avoids  any  stretching  of  the  tendou,  and  insures 
a  well-placed  pad  under  the  heel,  but  it  shortens  the  limb 
somewhat,  and  places  the  point  of  support  behind  the  axis 
of  the  leg.  Pasquier  saws  both  tibia  and  calcaneum  hori- 
zontally;  this  is  difficult  of  execution,  endangers  the  flap, 
and  also  leaves  the  point  of  the  heel  too  far  back.  The  sug- 
gestion which  is  occasionally  made  to  retain  the  malleoli 
is  unsurgical  and  unprofitable — unsurgical,  because  union 
between  two  cut  surfaces  of  cancellous  bone  is  speedier, 

1  PirogofTs  incisions  were  nearly  identical  with  Syme's.  He  also  divided  the 
calcaneum  vertically,  and  left  in  the  articular  surface  of  the  tibia  unless  it  was 
diseased. 

2  Ure's  conception  of  the  operation  seems  to  have  been  original  with  him.  His 
case  was  published  in  the  Lancet  about  the  time  of  the  appearance  of  Pirogoff's 
book  at  Leipzig,  1854. 


102  OPERATIVE  SURGERY. 

stronger,  and  not  exposed  to  greater  risks  than  when  oue 
surface  is  covered  with  articular  cartilage ;  unprofitable, 
because  nothing  is  gained  in  accuracy  of  adjustment  or 
length  of  limb. 

Comparison  of  the  Different  Methods  of  Partial  and  Total 
Amputation  of  the  Foot.  As  an  offset  to  the  advantage  of 
their  less  extensive  mutilation,  Lisfranc's  and  Chopart's 
amputations  are  open  to  the  objection  that  the  unopposed 
action  of  the  muscles  of  the  calf  may  raise  the  heel  per- 
manently, and  bring  the  weight  of  the  body  upon  the  end 
of  the  stump  and  the  cicatrix  ;  and,  furthermore,  when  these 
amputations  have  been  performed  for  disease  of  the  bones, 
those  bones  which  were  left  behind,  even  if  entirely  healthy 
at  the  time  of  the  operation,  have  ultimately  become  affected. 

Syme's  amputation  gives  an  excellent  stump,  and  the 
shortening  of  the  limb  is  no  more  than  is  necessary  to  per- 
mit the  adaptation  of  an  artificial  foot  and  a  spring  under 
the  heel,  but  it  is  comparatively  difficult  of  execution,  and 
the  flap  is  liable  to  pouch  and  favor  retention  of  the  pus. 
Pirogoff's  method  is  easier  of  execution  and  gives  a  longer 
limb,  but  an  artificial  foot  cannot  be  fitted  to  it  so  advan- 
tageously, and  in  cases  of  amputation  for  disease  it  is  con- 
trary to  sound  principles  of  surgery  to  leave  in  the  stump 
any  bone  which  is  apt  to  become  subsequently  affected ;  it 
brings  the  heel  pad  a  little  too  far  forward,  and  requires  a 
longer  time  for  recovery  from  the  operation.  The  subastra- 
galoid  disarticulation  gives  a  longer  limb  and  a  good  stump, 
but  disease  is  apt  to  recur  in  the  astragalus. 

(See  also  Mikulicz's  osteoplastic  excision  of  the  heel.) 


AMPUTATION    OF   THE    LEG. 

A.  Lower  Third.  This  may  be  done  by  the  pure  cir- 
cular or  by  a  modified  circular  method,  with  a  long  anterior 
Hap  made  to  overhang  the  square-cut  posterior  segment  of 
the  limb,  or  with  a  long  elliptic  posterior  flap,  including  the 
whole  of  the  tendo  Achillis.  The  two  former  result  in  a 
central  adherent  cicatrix  ;  in  all  the  coverings  are  liable  to 
be  thin  and  tender,  and  the  artificial  limb  must  be  so  ad- 


AMPUTATIONS. 


103 


justed  that  the  weight  will  be  received  by  the  sides  of  the 
leg  and  not  upon  the  face  of  the  stump.     The  compensatory 


Fig.  46. 


Fig.  47. 


Fig.  46.— Amputation  of  leg.  A.  Modified  circular.  B.  Rectangular  flaps, 
Teale.    C.  Antero-posterior  flaps,  upper  third,  Bell. 

Fig.  47.— Amputation  ofleg.  A.  Long  anterior  flap.  B.  Supra-malleolar  ampu- 
tation by  long  posterior  flap,  Guyon.  C.  At  the  upper  third,  Sedillot.  D.  Skin 
flaps  and  circular  division  of  the  muscles. 

advantages  are  that  the  control  of  the  limb  is  more  perfect 
than  with  a  shorter  stump,  and  the  mortality  consequent 
upon  the  operation  less. 


104  OPERATIVE  SURGERY. 

1.  Circular  Method.  A  circular  incision  is  made  through 
the  skin,  and  a  cutaneous  sleeve  one  inch  long  behind,  two 
inches  in  front,  is  dissected  up ;  the  soft  parts  are  cut 
straight  through  to  the  bone  at  the  base,  and  then  retracted 
with  a  two-  or  three-tailed  band,  according  to  the  breadth 
of  the  interosseous  membrane,  and  the  bones  sawn  through, 
beginning  and  endings  with  the  tibia. 

Brunts  Method}  "While  the  skin  is  strongly  drawn  up, 
a  circular  incision  is  made  down  to  the  bone  at  a  distance 
below  the  future  saw-line  equal  to  two-thirds  of  the  diam- 
eter of  the  leg  at  the  saw-line.  Liberating  incisions  about 
two  inches  long  are  carried  upward  from  the  circular  in- 
cision, dividing  all  the  soft  parts  over  the  inner  border  of 
the  tibia  and  the  outer  aspect  of  the  fibula,  the  latter  being 
reached  through  the  intermuscular  septum.  Without  dis- 
turbing the  attachments  of  the  overlying  soft  parts,  the 
periosteum  is  carefully  raised  from  the  tibia  and  fibula  as 
high  as  the  lateral  liberating  incisions  extend,  and  first  the 
fibula  and  then  the  tibia  are  sawn  through,  the  latter  ob- 
liquely to  prevent  projection  of  the  crest.  The  vessels  are 
then  ligated,  the  extremities  of  the  tendons  excised,  and 
buried  sutures  passed,  uniting  the  muscles  and  periosteum, 
and,  after  rounding  off  the  corners,  the  wound  is  closed 
with  a  drain  in  the  upper  augle  of  the  lateral  incisions. 

In  the  upper  half  of  the  leg  the  circular  incision  is  made 
first  through  the  skin,  and  then  the  muscles  are  divided  a 
finger's- breadth  higher  up. 

2.  Modified  Circular.  Fig.  46,  A.  Circular  incision 
through  the  skin,  met  by  a  liberating  longitudinal  one  on 
the  autero-external  aspect.  The  soft  parts  of  the  posterior 
portion  are  divided  rather  lower  than  those  of  the  anterior 
portion,  and  all  are  dissected  back  to  the  line  at  which  the 
bones  are  to  be  divided. 

Instead  of  a  single  liberating  incision  two  may  be  made, 
one  on  each  side  ;  and  then  by  rounding  off  the  corners  we 
may  have  double  skin  flaps  with  circular  division  of  the 
muscles,  the  "modified  flap"  operation. 

3.  Long  Anterior  Flap  (Bell).  Fig.  47,  A.  An  ante- 
rior flap,  equal  in  length  to  the  diameter  of  the  leg  at  its 

1  Bcitragc  zur  kiln.  Chlr.,  189:5.  p.  402. 


AMPUTATIONS. 


105 


Fig.  48. 


base,  is  marked  out  by  a  curved  incision  through  the  skin, 
beginning  at  the  posterior  edge  of  the  tibia  on  the  inner  side, 
a  little  below  the  point  at  which  the  bones  are  to  be  divided, 
and  ending  at  a  point  directly  oppo- 
site over  the  fibula.  The  anterior 
muscles  are  divided  transversely  half 
an  inch  above  the  lower  end  of  the 
flap,  and  carefully  dissected  off  the 
bones  and  interosseous  membrane  as 
high  as  the  base  of  the  flap.  The  sep- 
aration from  the  interosseous  mem- 
brane should  be  made  with  the  finger 
or  handle  of  the  knife,  in  order  that 
the  anterior  tibial  artery  which  lies 
immediately  upon  the  membrane 
may  not  be  injured.  The  posterior 
flap  is  then  made  by  transfixion  and 
cutting  transversely  outward,  and, 
the  soft  parts  being  retracted,  the 
bones  are  sawn  across  a  little  higher 

UP-  ... 

The  resulting  cicatrix  is  posterior 

and  not  adherent  to  the  end  of  the 
bone.  Bell1  reports  five  cases,  in  all 
of  which  there  was  complete  and 
rapid  recovery,  with  a  useful  stump. 
4.  Elliptic  Posterior  Flap 
(Guyon2).  Figs.  47  and  48,  B. 
The  incision  is  made  in  the  form  of 
an  ellipse,  whose  lower  end  crosses 
the  heel  below  the  insertion  of  the 
tendo  Achillis,  and  whose  upper  end 
is  about  an  inch  above  the  anterior 
articular  edge  of  the  tibia.  Begin- 
ning at  the  lower  end  aud  dividing 
the  tendo  Achillis  at  its  insertion, 
and  hugging  the  bone  all  the  way, 
the  flap  is  dissected  up  posteriorly  as 
high  as  the  upper  end  of  the  ellipse. 


Amputation  of  the  leg  and 
at  the  knee.  A.  Long  pos- 
terior rectangular  flap,  Lee. 

B.  Supra-malleolar,  Guyon. 

C.  At  the  upper  third,  Sedil- 
lot.  D.  Disarticulation  at  the 
knee,  oval  incision. 


i  Manual  of  Surg.  Operations,  3d  ed.,  p.  85.    Edinburgh,  1874. 
-  Bulletins  de  la  Societe  de  Chirurgie,  1868,  page  337. 


106  OPERATIVE  SURGERY. 

The  anterior  muscles  are  then  divided  by  transfixion,  the 
bones  sawn  through,  and  the  posterior  tibial  nerve  resected. 
In  this  operation  the  sheath  of  the  tendo  Achillis  is  not 
opened,  and  the  tendon  itself  serves  afterward  as  a  cover- 
ing for  the  end  of  the  bone.  The  retraction  of  the  muscles 
of  the  calf  tends,  in  the  course  of  time,  to  draw  the  cicatrix 
downward  and  backward,  and  Faraboeuf  has  proposed  to 
meet  this  tendency  by  carrying  the  anterior  end  of  the 
ellipse  still  further  up  the  leg,  so  that  that  part  of  the 
incision  through  the  skin  shall  be  an  inch  or  so  above  the 
line  of  division  of  the  bones  and  anterior  muscles. 

B.  Middle  Third.  1.  Long  anterior  curved  flap. 
2.  Simple  posterior  flap.  3.  Skin  flap  and  circular  divi- 
sion of  the  muscles. 

1.  The  long  anterior  curved  flap  is  made  according  to 
the  method  described  for  its  use  in  the  lower  third.  The 
principal  points  to  be  borne  in  mind  are  to  separate  the 
anterior  muscles  from  the  interosseous  membrane  with  the 
finger  or  handle  of  the  knife,  to  make  the  flap  long  enough 
to  fall  over  and  cover  the  broad  posterior  surface  of  section 
without  tension,  and  to  saw  off*  obliquely  the  prominent 
angle  made  by  the  crest  of  the  tibia. 

2.  Single  Posterior  Flap.  When  the  muscles  have  be- 
come atrophied  a  single  posterior  flap  may  be  safely  made. 
A  transverse  incision  is  made  across  the  front  of  the  leg 
from  the  posterior  edge  of  one  bone  to  that  of  the  other, 
and  a  long  posterior  flap  cut  from  within  outward,  by 
transfixion.  Its  length  should  be  equal  to  the  diameter  of 
the  leg  at  its  base. 

3.  Skin  Flaps  arid  Circular  Division  of  the  Muscles. 
Fig.  47,  I).  Longitudinal  incisions  are  made  on  the  ante- 
rior and  posterior  aspects  of  the  leg,  midway  between  the 
tibia  and  fibula.  They  should  extend  downward  from  a 
point  about  an  inch  below  the  future  saw-line  to  a  point  at 
a  distance  from  the  saw-line  equal  to  two-thirds  of  the 
diameter  of  the  leg  where  the  bone  is  to  be  divided.  These 
are  joined  by  transverse  incisions  with  the  corners  slightly 
rounded.  The  incisions  are  carried  through  the  skin  and 
subcutaneous  tissue,  and  the  flaps  thus  formed  are  turned 
back,  drawn  up,  and  dissected  from  the  fascia,  with  care  to 


AMPLIATIONS.  107 

include  all  the  subcutaneous  cellular  tissue,  till  the  point  of 
bone  division  is  nearly  reached. 

The  muscles  are  then  cut  transversely  through  to  and 
between  the  bones,  the  interosseous  membrane  divided,  a 
three-tailed  retractor  applied,  and,  after  circular  division  of 
the  periosteum,  the  bones  are  sawn,  finishing  with  the  fibula 
first.  The  cicatrix  will  lie  between  the  tibia  and  fibula. 
This  is  generally  the  best  method  for  amputation  of  the  leg. 

C.  Upper  Third.  (" Place  of  Election")  The  bones 
should  never  be  divided  above  the  attachment  of  the  liga- 
mentum  patellae  to  the  tuberosity  of  the  tibia,  and  it  is 
better  to  divide  two  inches  below  it,  when  possible,  so  as 
not  to  open  the  sheaths  of  the  flexor  muscles  of  the  thigh. 
Baron  Larrey  preferred  to  make  the  section  obliquely 
upward  and  backward,  beginning  at  the  middle  of  the 
attachment  of  the  ligamentum  patellae.  He  claimed  that 
this  could  be  done  without  opening  the  knee-joint,  and  that 
the  greater  vitality  of  the  spongy  tissue  made  recovery 
more  rapid.  The  head  of  the  fibula  should  not  be  removed, 
because  in  a  certain  proportion  of  cases  the  upper  tibio- 
fibular articulation  communicates  with  that  of  the  knee. 
The  circular  and  the  various  flap  methods  may  be  em- 
ployed. 

4.  Long  Anterior  Rectangular  Flap  (Teale).1  Fig.  46, 
B.  The  following  two  methods  have  been  practically 
abandoned  on  account  of  the  great  sacrifice  of  sound 
parts  which  they  entail.  From  each  end  of  the  transverse 
diameter  of  the  leg  at  the  point  at  which  the  bones  are  to 
be  divided  an  incision,  equal  in  length  to  half  the  circum- 
ference of  the  leg  at  that  point,  is  made  downward  and 
slightly  backward,  so  that  the  two  shall  be  as  far  apart  as 
they  are  at  their  upper  ends,  measuring  across  the  front  of 
the  leg.  Their  lower  extremities  are  then  united  by  a 
transverse  anterior  incision  carried  through  to  the  bones  and 
interosseous  membraue.  The  flap  thus  marked  out  is  dis- 
sected up  to  its  base,  the  separation  from  the  interosseous 
membrane  being  made  with  the  finger  or  handle  of  the 
knife  so  as  not  to  injure  the  anterior  tibial  artery. 

1  See  also  page  93. 


108  OPERATIVE  SURGERY. 

A  posterior  flap,  one-fourth  the  length  of  the  anterior 
one,  is  next  cut  by  a  transverse  incision  straight  down  to 
the  bones,  and  dissected  back  to  the  same  point,  the  inter- 
osseous membrane  divided,  the  bones  cleaned  and  sawn 
through. 

The  long  flap  is  then  doubled  back  upon  itself,  its  lower 
end  sewed  to  that  of  the  posterior  flap,  aud  the  edges  of  the 
lateral  incisions  fastened  together. 

5.  Long  Posterior  Rectangalar  Flap  (Lee).  Fig.  48, 
A.  The  incisions  are  similar  to  those  used  in  Teale's 
method,  but  they  involve  only  the  skin,  and  the  short  flap 
is  anterior,  the  long  one  posterior.  The  posterior  flap  con- 
tains only  the  gastrocnemius  aud  soleus,  while  the  deeper 
layer  of  muscles,  together  with  the  large  vessels  and  nerves, 
is  cut  transverely  as  high  as  the  lateral  incisions  permit. 

1.  Modified  Flap  (Bell).  Fig.  46,  C.  Two  equal  semi- 
lunar flaps  of  skin  three  inches  long,  one  antero-external, 
the  other  postero-internal,  their  extremities  meeting  at  oppo- 
site points  about  two  inches  below  the  tuberosity  of  the 
tibia.  These  must  be  reflected  up,  and  with  them  another 
inch  of  skin,  embracing  the  whole  circumference  of  the  limb, 
must  be  dissected  up.  The  anterior  muscles  must  be  cut  as 
high  as  exposed,  and  the  posterior  ones  about  the  middle  of 
their  exposed  surface.  The  bones  must  then  be  sawn  as 
high  as  exposed,  the  fibula  being  finished  first,  and  the 
sharp  prominence  of  the  edge  of  the  tibia  removed. 

Large  External  Flap  (Faraboeuf ).  An  incision  involv- 
ing the  skin  only  is  begun  at  the  level  at  which  the  bone 
is  to  be  divided,  aud  carried  vertically  downward  close  to 
the  inside  of  the  anterior  border  of  the  tibia,  a  distance 
nearly  equal  to  the  diameter  of  leg  at  the  proposed  point 
of  section.  Thence,  with  slightly  rounded  corners,  it  passes 
horizontally  across  the  outer  aspect  of  the  leg  and  vertically 
up  behind,  opposite  the  anterior  incision,  to  terminate  an 
inch  and  a  half  below  the  level  of  the  starting  point.  After 
retracting  the  skin  and  subcutaneous  tissue  the  deep  fascia 
is  cut  along  the  crest  of  the  tibia,  and  the  underlying  soft 
parts  separated  from  the  external  surface  of  this  bone  and 
from  the  interosseous  membrane  mainly  by  a  blunt  dissec- 
tion to  avoid  wounding  the  anterior  tibial  artery,  upon 
which  the  vitality  of  the  flap  largely  depends.     While  the 


AMPUTATIONS.  109 

fingers  are  inserted  in  the  gap  thus  made,  the  muscles  are 
divided  obliquely  downward  and  outward  to  the  margin  of 
the  retracted  skin,  thus  making  the  external  flap  quite  thin 
at  its  lower  edge.  The  dissection  must  not  be  carried  high 
enough  to  injure  the  artery  where  it  pierces  the  interosseous 
membrane. 

The  ends  of  the  anterior  and  posterior  incisions  are  now 
united  by  one  through  the  skin,  curving  slightly  downward 
across  the  inner  aspect  of  the  limb,  and  the  underlying  soft 
parts  cut  by  transfixion  at  this  level  and  separated  from  the 
bone  up  to  the  point  of  the  proposed  saw-line.  The  inter- 
osseous membrane  is  then  pierced  and  the  periosteum  of 
the  tibia  divided  circularly  and  the  bone  bared  for  a  short 
distance.  The  fibula  is  sawed  obliquely  on  its  external 
surface  from  without  downward  and  inward,  the  stump 
being  made  about  half  an  inch  shorter  than  the  tibia.  The 
latter  is  then  cut  transversely  and  its  projecting  crest  and 
internal  border  removed. 

The  anterior  tibial  artery  is  divided  in  the  free  edge  of  the 
external  flap,  while  the  posterior  tibial  and  the  peroneal 
arteries  lie  in  the  same  plane  on  the  tibialis  posticus  mus- 
cle, and  are  cut  transversely  close  together.  The  resulting 
cicatrix  is  on  the  inner  side  of  the  leg. 

COMPAEISON   OF   THE   DIFFERENT   METHODS. 

Amputation  in  the  lower  third  is  less  fatal  than  amputa- 
tion at  a  higher  point,  and  gives  better  command  of  the 
limb,  but  the  coverings  of  the  stump  are  liable  to  be  too 
thin  and  tender.  The  circular  and  double  flap  methods 
formerly  gave  central  cicatrices  and  stumps  that  would  bear 
no  weight  upon  their  face,  and  were  sometimes  so  sensitive 
that  even  the  pressure  of  a  stocking  could  hardly  be  borne. 
Guyon's  long  posterior  flap  taken  from  the  heel  promises 
well ;  in  the  first  case  reported  the  cicatrix,  six  weeks  after 
the  operation,  was  two  inches  above  the  end  of  the  stump, 
upon  which  forcible  pressure  could  be  made  without  caus- 
ing any  pain.1 

1  In  a  letter  to  me,  dated  June,  1877,  Prof.  Guyon  states  that  he  has  amputated 
four  times  by  this  method,  and  has  every  reason  to  be  satisfied  with  the  result. 
The  patients  bore  their  weight  upon  the  "stump  as  freely  as  upon  the  other  foot. 
Two  cases  are  reported  in  the  Bull,  dela  Soc.  de  Chirurgie,  1877,  p.  321.— L.  A.  S. 

6 


HO  OPERATIVE  SURGERY. 

The  long  anterior  flap  also  yields  a  cicatrix  which  is 
placed  posteriorly  and  out  of  the  way  of  pressure,  and  in 
short  it  may  be  said  that  the  reasons  which  made  the  upper 
third  the  place  of  election  have  lost  their  force  since  ampu- 
tation by  a  long  single  flap  has  been  shown  to  be  practicable 
at  any  point. 

After  amputation  in  the  upper  third  the  weight  of  the 
body  may  be  borne  upon  the  tough  skin  below  the  patella, 
the  patient  kneeling  upon  his  artificial  leg ;  or  the  stump 
may  fit  into  the  hollow  eud  of  an  artificial  limb,  the  upper 
edge  of  which  will  receive  the  weight  from  the  lower  edge 
of  the  patella  and  the  broader  bony  surfaces  near  the  joint. 
In  either  case  motion  at  the  joint  is  preserved,  and  there  is 
no  pressure  upon  the  cicatrix. 

In  children  methods  of  amputating  which  retain  in  the 
flap  a  considerable  strip  of  the  periosteum  of  the  removed 
bone  are,  as  a  rule,  to  be  avoided,  because  of  the  proba- 
bility of  an  objectionable  formation  of  bone  by  it,  the  so- 
called  "  physiological  conicity." 

AMPUTATION   AT   THE   KNEE. 

Under  this  head  are  ranged  pure  disarticulations  and 
amputations  through  the  condyles  of  the  femur.  In  dis- 
articulating, the  lateral  aud  crucial  ligaments  should  be 
divided  near  their  attachments  to  the  femur,  and  the  semi- 
lunar cartilages  removed. 

A.  Disakticulation.  Long  Anterior  Flap.  Fig.  49, 
A.  A  tongue-shaped  flap  is  marked  out  by  an  incision 
beginning  half  an  inch  below  the  line  of  the  articulation 
nearly  as  far  back  as  the  posterior  border  of  the  condyle 
on  one  side,  and  ending  at  the  corresponding  point  on  the 
other,  after  crossing  the  leg  five  inches  below  the  patella. 
A  transverse  posterior  incision  unites  the  sides  of  the  first 
an  inch  below  its  ends.  The  flap  is  dissected  up  and  the 
disarticulation  completed  as  before. 

Prof.  Pancoast  has  modified  the  operation  by  making 
inside  of  a  single  short  posterior  flap  two  small  semilunar 
postero-lateral  ones,  meeting  in  the  centre  of  the  popliteal 
space. 


AMP  VTA  TIONS.  1 1 1 

Lateral  Haps  (Stephen  Smith1).  "  Commence  an  incision 
about  an  inch  below  the  tubercle  of  the  tibia  aud  cut  to  the 
bone  ;  carry  it  downward  aud  forward  beyond  the  curve 
of  the  sides  of  the  leg,  thence  inward  and  backward  to  the 
middle  of  the  leg,  theuce  upward  to  the  middle  of  the  pop- 
liteal space  ;  repeat  this  iucision  upon  the  opposite  side ; 
raise  the  flap  consisting  of  all  the  tissues  down  to  the  bone  ; 
until  the  articulation  is  reached  divide  the  lateral  ligaments, 
enter  the  joint  and  sever  its  connections  internally  and  ex- 
ternally." 

B.  Amputation  through  the  Condyles.  Oval 
Method.  An  oval  incision  crossing  the  front  of  the  leg 
three  finger-breadths  below  the  end  of  the  patella  and  the 
back  three  finger-breadths  higher  than  in  front  is  made 
through  the  skin,  which  is  reflected,  and  the  joint  opened 
above  instead  of  below  the  patella,  which  is  not  included 
in  the  flap.  The  line  of  incision  is  similar  to  that  in  Fig. 
48,  D,  but  higher.  After  disarticulation  has  been  effected, 
the  posterior  soft  parts  divided,  aud  the  artery  tied,  the  con- 
dyles are  sawn  through  above  the  edge  of  the  articular 
cartilage.  Or  the  saw  may  be  applied  without  having 
previously  disarticulated. 

Anterior  Flap  (Carden1).  Fig.  49,  B.  "  The  operation 
consists  in  reflecting  a  rounded  or  semi- oval  flap  of  skin  and 
fat  from  the  front  of  the  joint ;  dividing  everything  else 
straight  down  to  the  bone  ;  and  sawing  the  bone  slightly 
above  the  plane  of  the  muscles  :  thus  forming  a  flat-faced 
stump  with  a  bonnet  of  integument  to  fall  over  it. 

"  The  operation  is  simple  and  is  performed  easily  in  two 
ways. 

"The  operator,  standing  on  the  right  side  of  the  limb, 
seizes  it  between  his  left  forefinger  and  thumb  at  the  spots 
selected  for  the  base  of  the  flap,  and  enters  the  point  of  his 
knife  close  to  his  finger,  bringing  it  round  through  skin  aud 
fat  below  the  patella  to  the  spot  pressed  by  his  thumb  ;  then 
turning  the  edge  downward  at  a  right-angle  with  the  line 
of  the  limb,  he  passes  it  through  to  the  spot  where  it  first 
entered,  cutting  outward  through  everything  behind  the 

1  Smith's  Operat.  Surg.,  p.  627.  -  British  Med.  Journal,  April  16,  1864. 


112 


OPERATIVE  SURGERY. 


Fig.  49. 


bone.     The  flap  is  then  reflected,  and  the  remainder  of  the 
soft  parts  divided  straight  down  to  the  bone  j1  the  muscles 
are  then  slightly  cleared  upward, 
and  the  saw  is  applied. 

"  Or  the  flap  may  be  reflected 
first  and  the  knee  examined,  par- 
ticularly if  the  operator  be  unde- 
cided between  resection  and  ampu- 
tation. In  amputating  through 
the  condyles,  the  patella  is  drawn 
down  by  flexing  the  knee  to  a 
right-angle  before  dividing  the 
soft  parts  in  front  of  the  bone;  or 
if  that  be  inconvenient  the  patella 
may  be  reflected  downward.  .  .  . 
"  The  flap  falls  easily  over  the 
end  of  the  bone,  and,  when  united 
to  the  posterior  integuments  by  a 
few  pins  and  sutures,  is  drawn 
strongly  upward  and  backward  by 
the  greatly  retracted  flexors,  and 
has  a  somewhat  puckered  and  re- 
dundant appearance  at  first.  .  .  ." 
GritWs  Modification.  This  is 
the  analogue  of  Pirogoft's  modifi- 
cation of  Syme's  amputation  at  the 
ankle.  The  articular  surface  of 
the  patella  is  removed  and  the  cut 
surface  of  the  bone  applied  against 
that  of  the  femur.  The  natural 
mobility  of  the  skin  over  the 
patella  is  preserved,  and  the  use- 
fulness of  the  stump  increased 
thereby ;  but  it  not  unfrequently 
happens  that  the  patella  is  drawn 
upward  by  the  quadriceps  femoris, 
and  union  does  not  take  place  between  the  two  bones. 
Gritti  sawed  through  the  femur  at  the  upper  edge  of  the 
articular  surface,  but  I  have  always  found  it  advisable  to 


Amputation  at  the  knee  and 
lower  third  of  thigh.  A.  Dis- 
articulation, long  anterior  flap. 
B.  Amputation  through  the 
condyles,  Carden.  C.  Modified 
flap  amputation  at  the  lower 
third  of  the  thigh,  Syme. 


Lister  and  Bell  recommend  a  posterior  skin  flap  one  inch  long. 


AMPUTATIONS. 


113 


go  nearly  au  inch  higher  in  order  to  prevent  tilting  of  the 
patella.    Von  Linhart1  claims  that  the  stump  is  better  than 


Fig.  50. 


A.  Gritti's  amputation  at  the  knee ;  A'.  Lines  of  division  of  the  bone.  B.  Long 
anterior  flap  (Sedillot) ;  B'.  Division  of  bone.  C.  Amputation  at  lower  third 
(Spence) ;  C".  Division  of  the  bone.    D.  Disarticulation  at  the  hip. 

that  obtained  by  amputation  in  the   lower  third   of  the 

femur,  but  not  better  than  that  obtained  by  disarticulation. 

A  rectangular  anterior  flap  (Fig.  50,  A)  extending  from 

1  Compend.  v.  Operationslehre,  1867,  p.  401. 


114  OPERATIVE  SURGERY. 

the  centre  of  the  condyles  to  the  tuberosity  of  the  tibia  is 
marked  out,  and  dissected  up  after  division  of  the  ligamen- 
tuni  patellae  as  near  as  possible  to  its  insertion ;  the  skin 
covering  the  back  of  the  knee  is  divided  transversely,  or  by 
an  incision  curved  slightly  downward,  the  anterior  flap 
turned  back,  the  synovial  membrane  separated  from  its 
attachment  to  the  femur,  and  the  bone  sawn  through  well 
above  the  edge  of  the  articular  cartilage,  but  below  the 
medullary  canal.  The  remaining  soft  parts  are  then  divided 
from  within  outward,  and  the  vessels  secured.  The  articu- 
lar surface  of  the  patella  may  be  sawn  off  or  removed  with 
cutting-pliers,  and  this  step  in  the  operation  is  facilitated 
by  having  the  ligamentum  patellae  cut  long,  so  that  it  can 
be  used  to  hold  the  bone  firmly. 


AMPUTATION   OF   THE   THIGH. 

The  central  position  of  the  femur,  and  the  abundance  of 
the  soft  parts,  have  made  it  possible  to  employ  a  great 
variety  of  methods  of  amputation,  but  the  superiority  of 
the  flap  operation  is  now  generally  admitted,  with  certain 
modifications  depending  upon  the  portion  of  the  limb 
selected  for  amputation.  Thus,  in  the  lower  third  when 
the  skin  over  the  patella  is  uninjured,  Teale's  or  Carden's 
method  is  to  be  'preferred  ;  when,  on  the  other  hand,  that 
portion  of  skin  is  unavailable,  the  long  anterior  flap,  or 
Sy rue's  modified  flap  operation,  should  be  used ;  aud  in 
order  to  compensate  for  the  greater  retraction  of  the  pos- 
terior muscles  they  should  be  cut  obliquely  instead  of  trans- 
versely in  the  former  operation,  aud  on  a  lower  level  than 
the  anterior  muscles  in  the  latter.  In  the  middle  third  the 
long  anterior  flap  is  to  be  preferred.  Lateral  flaps  should 
always  be  avoided  ou  account  of  the  tendency  of  the  bone 
to  project  at  the  upper  angle,  drawn  forward,  as  it  is,  by 
the  action  of  the  flexors  of  the  thigh  upon  the  pelvis. 

The  muscles  are  more  abundant  on  the  inner  and  pos- 
terior aspects,  and  this  disproportion  increases  toward  the 
hip.  The  femoral  artery  will  be  found  in  the  posterior- 
flap  below  the  middle  of  the  thigh,  in  the  anterior  flap 
above;   care  must  be  taken    not  to   include  the  internal 


AMP  UTA  TIONS.  115 

saphenous  nerve  in  the  ligature  placed  upon  it.  The  pro- 
funda artery  lies  close  behind  the  bone,  but  divides  early 
into  its  branches.  The  sciatic  nerve  lies  between  the  short 
head  of  the  biceps  and  the  adductor  maguus;  it  should  be 
drawn  gently  downward  and  divided  again  high  up. 

Sometimes  the  band  of  the  tourniquet  prevents  the  mus- 
cles from  retracting  sufficiently  to  allow  the  bone  to  be 
cleared  to  the  proper  height.  Under  such  circumstances 
the  bone  should  be  divided  wherever  it  is  most  convenient, 
and  the  excess  sawn  off  after  the  vessels  have  beeu  tied. 

Teak's  and  Garden's  methods  have  been  sufficiently  de- 
scribed.    (See  pp.  70,  111.) 

Modified  Flap  Operation  in  the  Lotoer  Third  (Syme). 
(Fig.  49,  C.)  Two  equal  semilunar  flaps  of  skin  and  fat, 
one  anterior,  the  other  posterior,  are  made,  raised  from  the 
fascia,  and  retracted  two  inches  further ;  "  the  muscles 
should  then  be  divided  right  down  to  the  bone,  on  a  level 
as  high  as  they  are  exposed  in  front,  as  low  as  they  are 
exposed  behind."  The  bone  is  then  cleared  and  sawn 
through  two  inches  above  the  level  of  division  of  the  ante- 
rior muscles. 

Long  Anterior  Flap.  Sedillot,1  writing  in  1854,  says 
he  has  used  this  method  exclusively  for  the  preceding  seven 
years.  S pence2  describes  a  method  as  first  practised  by 
himself  in  1858,  and  claims  that  his  "  flap  is  formed  on  a 
principle  essentially  different  from  that  which  regulates  the 
construction"  of  Sedillot's,  a  difference  which  is  not  recog- 
nizable in  the  descriptions,  the  length  of  the  flap  in  each 
case  being  equal  to  the  diameter  of  the  limb,  the  breadth  of 
its  base  "almost  two  thirds  of  the  circumference"  accord- 
ing to  Sedillot,  "fully  equal  to  one-half  the  circumference  " 
according  to  Spence,  and  the  muscle  contained  in  it  cut  ob- 
liquely by  both,  so  that  it  shall  not  be  too  thick.  Sedillot 
divides  the  posterior  segment  of  the  limb  transversely. 
Spence  divides  it  obliquely  from  without  inward,  beginning 
two  inches  below  the  base  of  the  anterior  flap,  and  some- 

1  Medecine  Opfiratoire,  2d  edition,  vol.  i.  p.  455. 

2  Lectures  on  Surgery,  2d  edition,  vol.  ii.  p.  621,  Edinb.,  1876. 


116  OPERATIVE  SURGERY. 

times  takes  an  additional  inch  of  skin,  a  difference  which 
approximates  his  method  to  Teale's.  Benjamin  Bell  also 
describes  a  method  which  is  nearly  identical,  and  O'Hallo- 
ran  used  a  similar  one  in  1765,  but  his  flap  was  too  short 
to  accomplish  its  purpose. 

Sedillot's  description  is  as  follows  (Fig.  50,  B) : 
The  flesh  of  the  anterior  aspect  of  the  limb  is  grasped  in 
the  left  hand,  and  an  incision  made  through  the  skin,  mark- 
ing out  a  flap  whose  length  is  equal  to  one-third,  and  its 
base  to  almost  two-thirds  of  the  circumference  of  the  limb. 
The  muscles  are  then  divided  obliquely  upward  and  back- 
ward so  that  the  flap  shall  not  be  too  thick,  the  posterior 
segment  of  the  limb  divided  transversely,  the  bone  cleared 
an  inch  or  two  higher  and  sawn  through.  He  also  removes 
the  anterior  edge  of  the  bone  obliquely,  as  was  recommended 
for  the  tibia. 

Spence  recommends  the  long  anterior  flap  as  especially 
applicable  to  amputation  in  the  lower  third,  and  he  makes 
it  as  low  as  possible,  so  that  its  lower  margin  is  on  a  level 
with  or  below  the  patella.  After  dissecting  up  the  skin  to 
the  upper  end  of  the  patella,  he  cuts  obliquely  upward 
through  the  anterior  muscles  to  the  bone  immediately  above 
the  condyles  (Fig.  50,  C).  While  the  soft  parts  are  re- 
tracted, and  after  the  bone  has  been  cleared  circularly,  he 
elevates  the  femur  so  as  to  project  it  fully,  and  divides  it 
two  inches  above  the  base  of  the  flap. 

Modified  Circular  Amputation  in  the  Lower  Third.  The 
incision,  involving  only  the  skin,  is  begun  at  the  outer 
part  of  the  anterior  surface  of  the  thigh,  at  a  distance  below 
the  proposed  saw-line  equal  to  one-quarter  of  the  circum- 
ference of  the  limb  at  the  level  where  the  bone  is  to  be 
divided.  It  is  carried  obliquely  downward  across  the  front 
of  the  thigh,  and  then  transversely  across  the  inner  and 
posterior  aspects  at  a  distance  below  the  proposed  saw-lino 
equal  to  one-third  of  the  circumference  already  taken,  and 
finally  upward  on  the  outer  aspect  to  the  point  at  which  it 
began.  The  skin  is  next  retracted  and  freed  all  around  for 
about  two  inches. 

The  superficial  muscles  on  the  inner  and  posterior  aspects 
of  the  thigh  are  divided  at  the  level  of  the  retracted  skin, 


AMPUTATIONS.  117 

and  then  the  outer  and  deeper  muscles  are  severed  down  to 
the  bone  at  the  highest  possible  level. 

In  cutting  the  muscles  the  obliquity  of  the  original 
incision  is  to  be  maintained.  Retractors  are  now  applied 
and  the  bone  sawed,  taking  care  not  to  leave  a  projecting 
spike  at  the  linea  aspera. 


AMPUTATION    AT   THE    HIP-JOINT. 

The  affections  which  render  this  most  serious  operation 
necessary  are  often  of  such  a  nature  that  the  surgeon's 
choice  of  a  method  of  performing  it  is  greatly  restricted  ; 
he  must  take  his  flaps  where  he  can  get  them,  and  must 
regulate  his  incisions  by  existing  lesions.  Moreover,  the 
problem  is  not  to  obtain  a  flap  that  will  bear  pressure,  but 
to  remove  the  limb  in  the  manner  that  involves  the  least 
risk  to  life.  This  risk,  which  has  proved  very  great,  is  due 
not  only  to  the  gravity  of  the  lesions  which  render  surgical 
interference  necessary,  but  also  to  three  causes  which  origi- 
nate in  the  operation  itself.  These  are  loss  of  blood,  shock, 
and  septicaemia.  The  first  two  are  the  principal  dangers, 
as  modern  methods  have  minimized  the  chances  of  infec- 
tion, although  formerly  they  were  considerable. 

The  opinion,  held  by  many,  that  the  amount  of  shock 
varied  directly  with  the  length  of  time  employed  in  remov- 
ing the  limb,  led  to  the  introduction  of  operative  methods 
characterized  by  extreme  rapidity  of  execution,  not  more 
than  thirty  seconds  being  allowed  for  the  removal  of  the 
limb  from  the  body ;  the  type  of  these  is  the  method  by  a 
long  anterior  flap  made  from  within  outward  by  transfixion. 

To  prevent  hemorrhage  many  expedients  have  been  em- 
ployed :  the  same  rapidity  of  execution ;  compression  of  the 
femoral  artery  upon  the  pubis,  or  within  the  flap  by  an 
assistant,  who  passes  his  fingers  into  the  wound  behind  the 
knife ;  compression  of  the  aorta ;  preliminary  ligature  of 
the  femoral  artery ;  ligature  of  each  vessel  when  encoun- 
tered in  the  wound  ;  laparotomy  and  digital  compression 
or  ligation  (q.  v.)  of  the  common  iliac ;  compression  by  an 
elastic  tourniquet  applied  above  steel  pins  thrust  through 
the  thigh.     The  hemorrhage  most  to  be  feared  is  that  from 

6* 


118  OPERATIVE  SURGERY. 

the  numerous  vessels  of  the  posterior  segment  of  the  thigh, 
for,  while  the  femoral  artery  can  usually  be  controlled 
without  much  difficulty,  there  is  no  way  of  preventing  the 
flow  of  blood  from  the  others  except  by  compression  of  the 
aorta  or  common  iliac  through  the  walls  of  the  abdomen, 
or  of  the  internal  iliac  through  the  rectum,  or  by  previ- 
ously securing  the  common  iliac  either  extra-  or  intra-peri- 
toneally.  The  latter  device,  first  suggested  as  a  means  of 
hemostasis  during  operation  for  gluteal  aneurism,  has  been 
employed  in  one  or  two  amputations  with  success ;  com- 
pression of  the  aorta,  although  effectual  and  entirely  harm- 
less in  some  cases,  has  proved  dangerous  or  impracticable  in 
others1  by  exciting  peritonitis  or  interfering  with  respiration. 

A  simple,  efficient,  and  probably  safe  method  is  one 
recently  devised  and  successfully  employed  by  Dr.  Mc- 
Burney ;  direct  compression  of  the  common  iliac  artery  by 
the  finger  introduced  through  an  incision  in  the  anterior 
abdominal  wall. 

Dr.  Wyeth2  uses  two  steel  mattress-needles  which  are 
thrust  through  the  thigh  to  prevent  the  slipping  of  an  elas- 
tic tourniquet  fastened  above  them.  After  applying  the  Es- 
march  bandage  from  the  toes  to  the  groin  the  first  needle 
is  entered  one  and  a  half  inches  below  and  just  to  the  inner 
side  of  the  anterior  superior  spine  of  the  ilium.  It  passes 
externally  to  the  neck  of  the  femur,  and  comes  out  just 
behind  the  great  trochanter  about  half-way  between  it  and 
the  posterior  superior  iliac  spine.  The  second  needle  is 
entered  an  inch  below  the  level  of  the  groin  internal  to  the 
saphenous  opening,  and,  passing  through  the  adductors, 
emerges  about  one  and  a  half  inches  in  front  of  the  tuber 
ischii.  A  stout  rubber  tube  is  then  wound  tightly  enough 
around  the  thigh  above  these  pins  to  occlude  the  vessels. 

Dr.  McBurney  has  also  used  in  two  cases,  and  apparently 
with  great  advantage,  intra- venous  injection  of  a  large 
quantity  of  normal  salt  solution  during  the  operation. 

The  position  of  the  joint  may  be  determined  by  that  of 
the  anterior  inferior  spine  of  the  ilium,  which  is  three- 
quarters  of  an  inch  above  its  upper  margin. 

1  See  Erekine  Mason,  "Two  Successful  Oases  of  Amputation  at  the  Hip-joint," 
N.  Y.  Med.  Journ.,  Dec.  1876. 

2  Journal  Am.  Med.  Assoc,  Feb.  7, 1891. 


AMP  VTA  TIONS.  119 

Nearly  all  of  the  numerous  methods  for  performing 
amputation  at  the  hip-joint  may  be  considered  as  variations 
to  a  greater  or  less  extent  from  the  operation  by  flaps,  which 
may  be  either  external  and  internal  or  anterior  and  pos- 
terior, and  by  the  anterior  and  the  external  oval — some- 
times called  racket — incision.  Disarticulation  by  external 
and  internal  flaps  is  not  to  be  commended  except  for  cases 
in  which  sound  tissue  cannot  be  obtained  elsewhere.  The 
knife  is  entered  about  a  hand's-breadth  vertically  below 
the  anterior  superior  spine  of  the  ilium  and  made  to  trans- 
fix the  thigh  from  before  backward  just  below  the  great 
trochanter ;  it  is  then  carried  down  and  out,  cutting  a  flap 
four  or  five  inches  long.  The  muscles  are  then  separated 
from  the  great  trochanter,  and  after  disarticulation  the 
inner  flap  is  cut  of  a  similar  length.  Hemorrhage  is  con- 
trolled by  the  pressure  of  an  assistant's  fingers  entered  in 
the  track  of  the  knife  and  by  ligation  of  each  vessel  as  soon 
as  possible  after  it  is  divided. 

When  the  nature  of  the  disease  or  injury  permits,  the 
operation  by  the  external  racket  incision  is  generally  given 
the  preference.  In  this  the  bone  is  approached  through  the 
least  vascular  area,  and  the  incision  can  also  be  used  for 
exploration  before  proceeding  to  amputation. 

I.  Anterior  Racket  or  Oval  Method.  The  patient  hav- 
ing been  anaesthetized  and  placed  upon  the  table,  an  Es- 
march's  elastic  band  is  applied  from  the  toes  as  far  upward 
as  is  allowed  by  the  nature  of  the  lesion  and  the  line  of  the 
proposed  incision. 

1.  An  incision,  beginning  a  finger's-breadth  below  Pou- 
part's  ligament,  is  carried  down  along  the  course  of  the 
femoral  artery  for  about  four  inches  ;  thence  outward  and 
downward,  crossing  the  great  trochanter  a  little  below  its 
base,  to  the  gluteal  fold  ;  thence  transversely  aloug  this 
fold  to  the  inner  side  of  the  thigh,  and  thence  obliquely 
upward  five  full  finger-breadths  below  the  genito-crural 
fold  to  the  point  where  it  diverged  from  the  line  of  the 
artery.  The  incision  should  involve  only  the  skin  and  the 
cellular  tissue;  any  vessels  that  are  divided  should  be  im- 
mediately tied. 

2.  The  sheath  of  the  vessels  is  opened,  the  artery  isolated 


120  OPERATIVE  SURGERY. 

and  denuded,  and  its  point  of  bifurcation  determined.  A 
ligature  is  then  applied  methodically  to  the  vessel  above 
the  origin  of  the  profunda,  and  a  second  lower  down, 
including  both  branches  en  masse,  and  the  artery  divided 
between  them.  The  femoral  vein  is  also  carefully  de- 
nuded and  divided  between  two  ligatures  at  about  the  same 
level. 

3.  The  incision  is  carried  down  through  the  muscles, 
beginning  on  either  the  outer  or  inner  side,  as  is  most  con- 
venient ;  on  the  inner  side,  after  having  cut  through  the 
adductors  at  the  junction  of  their  fleshy  and  tendinous  por- 
tions, seek  and  tie  the  obturator  vessels,  divide  the  pectineus 
and  psoas  on  a  line  with  the  neck  of  the  femur,  and  secure 
all  the  bleeding  points.  On  the  outer  side,  divide  the  sar- 
torius  and  the  fascia  lata,  and  then  adductthe  thigh  so  as  to 
throw  the  great  trochanter  forward  and  facilitate  the  division 
of  the  muscles  attached  to  it. 

4.  Open  the  articulation  in  front  and  divide  the  posterior 
portion  of  the  capsule  as  close  as  possible  to  the  femur, 
together  with  the  remaining  tendons  that  are  inserted  in 
the  great  trochanter. 

5.  Division  of  the  posterior  segment  of  the  limb.  De- 
press the  thigh  beyond  the  border  of  the  table,  so  as  to 
make  the  wound  gape  widely,  and  divide  the  remainder  of 
the  adductors  and  the  muscles  attached  to  the  ischium  with 
gentle  strokes  of  the  knife,  tying  each  vessel  when  it  is 
recognized  or  divided.  It  is  well  also  to  resect  the  ex- 
tremity of  the  sciatic  nerve. 

II.  External  Racket  Incision  or  Modified  Oval  Method. 
Fig.  50,  D.  The  patient  is  laid  upon  his  side,  his  hips  at 
the  foot  of  the  table.  A  straight  incision  four  inches  long 
is  begun  one  inch  above  the  summit  of  the  great  trochanter, 
and  carried  along  its  posterior  border,  and  a  circular  in- 
cisiOD  is  then  carried  from  the  lower  end  of  the  first  around 
the  thigh,  passing  three  inches  below  the  tuberosity  of  the 
ischium.  These  incisions  should  interest  the  skin  only, 
their  borders  should  be  dissected  up  for  about  an  inch,  and 
the  muscles  of  the  outer  aspect  divided  obliquely  upward 
toward  the  joint.  In  front  this  division  should  not  be  car- 
ried beyond  the  outer  edge  of  the  rectus  muscle,  but  pos- 


AMPUTATIONS.  121 

teriorly  it  should  be  as  extensive  as  possible  and  close  to 
the  bone. 

The  thigh  being  flexed  and  adducted,  the  capsule  is 
opened,  first  longitudinally  on  the  finger  as  a  guide,  then 
forward  and  backward  along  the  edge  of  the  cotyloid  cavity, 
the  head  of  the  femur  dislocated  backward  and  outward, 
the  knife  passed  around  it  and  brought  down  along  the 
inner  side  of  the  bone  nearly  to  the  level  of  the  circular 
incision,  and  then  made  to  cut  its  way  rapidly  out  on  the 
inner  side. 

Esmarch's  method  differs  slightly  from  this  last.  Hemor- 
rhage is  controlled  by  digital  pressure  on  the  femoral  in 
the  groin.  Five  inches  below  the  top  of  the  great  trochanter 
divide  everything  circularly  down  to  the  bone,  which  is  at 
once  sawn  across.  The  vessels  are  then  secured.  Next 
the  stump  of  the  femur  is  steadied  and  the  knife  entered 
about  two  inches  above  the  tip  of  the  trochanter  and  car- 
ried down  along  its  outer  surface  till  it  reaches  the  first  cir- 
cular incision.  The  bone  is  freed  from  soft  parts  by  an 
elevator  entered  beneath  the  periosteum,  aided  by  the  knife, 
the  muscular  insertions  on  the  trochanters  divided,  the 
capsule  opened,  and  the  bone  removed. 

III.  Anterior  Flap.  The  position  of  the  patient  being 
the  same,  and  the  thigh  slightly  flexed  and  abducted,  the 
point  of  a  long  amputating-knife  is  entered  midway  be- 
tween the  anterior  superior  spine  of  the  ilium  and  the  top 
of  the  great  trochanter  and  passed  inward  and  backward 
to  a  point  one  inch  below  and  in  front  of  the  tuberosity  of 
the  ischium,  grazing  the  anterior  surface  of  the  neck  of  the 
femur,  and  certainly  opening  the  capsule  of  the  joint  if  its 
edge  is  kept  turned  obliquely  toward  it.  (The  direction 
may  be  reversed  for  the  right  thigh,  the  knife  being  entered 
on  the  inner  side.) 

A  well-rounded  flap  ending  at  the  junction  of  the  upper 
and  middle  thirds  of  the  thigh  is  then  cut  with  rapid  saw- 
ing movements  of  the  knife,  and  reflected  upward.  The 
limb  is  forcibly  depressed,  and  if  the  capsule  has  been  well 
divided  this  movement  will  throw  the  head  of  the  femur 
forward  out  of  the  socket ;  and  if  not,  a  single  cut  with  the 
knife  across  the  head  of  the  bone  will  free  it.     The  leg  is 


122  OPERATIVE  SURGERY. 

then  rotated  inward  so  as  to  bring  the  trochanter  forward, 
the  surgeon  passes  the  knife  behind  the  head  of  the  bone 
and  cuts  a  short  posterior  flap  from  within  outward. 

Prof.  Van  Buren  divided  the  posterior  segment  from 
without  inward  by  a  sweep  of  the  knife  as  in  a  circular 
amputation,  and  then  disarticulated  and  divided  the  rotator 
muscles  with  a  scalpel. 

In  the  flap  operation  by  transfixion  the  assistant  who 
compresses  the  artery  against  the  pelvis  with  one  hand 
should  follow  the  knife  with  the  other,  and  grasp  the  vessel 
in  the  flap  between  his  fingers  and  thumb,  and  his  control 
of  it  should  be  such  that  the  surgeon  can  give  his  attention 
first  to  securing  the  numerous  vessels  of  the  posterior  seg- 
ment, the  bleeding  from  which  may  be  partly  checked  by 
pressure  with  dry  sponges  or  cloths  while  the  ligatures  are 
being  applied.  Or  the  bleeding  points  may  be  caught  up 
rapidly  with  artery-forceps,  and  the  ligatures  not  applied 
until  after  all  have  been  thus  secured. 

Serin's  Bloodless  Method}  Start  an  incision  on  the  outer 
surface  of  the  thigh  about  three  inches  above  the  trochanter, 
and  carry  it  vertically  downward  for  about  eight  inches, 
exposing  the  outer  surface  of  the  trochanter  and  femur. 

Keeping  close  to  the  bone,  separate  the  muscular  attach- 
ments to  the  great  trochanter,  and,  while  the  thigh  is  flexed, 
adducted,  and  rotated  inward,  open  the  capsule  transversely 
at  its  upper  posterior  aspect.  Sever  the  rest  of  the  liga- 
ments by  backward  dislocation  of  the  head  of  the  femur, 
which  is  then  pushed  out  of  the  wound  and  the  lesser 
trochanter  and  shaft  freed  as  low  as  desired. 

A  sinus-forceps  carrying  a  long  stout  piece  of  rubber- 
tubing  is  pushed  through  the  wound  behind  the  femur  at 
the  normal  level  of  the  lesser  trochanter,  emerging  through 
a  small  counter-opening  on  the  inner  surface  of  the  thigh, 
where  the  tube  is  cut  apart  and  the  vessels  occluded  by 
tying  the  anterior  segment  in  front  without  including  the 
femur ;  after  crossing  the  posterior  segment  behind  it  is 
brought  around  the  back  of  the  thigh  and  then  tied  in  front 
above  the  anterior  segment  of  tubing.     Starting  from  the 

i  Chic.  Clin.  Rev.,  Feb.  1893,  p.  343. 


EXCISION  OF  JOINTS  AND  BONES.  123 

points  of  emergence  of  the  tourniquet  a  long  anterior  and 
a  short  posterior  flap  are  raised,  consisting  of  all  the  tissues 
down  to  the  muscles,  which  are  then  cut  circularly  in  the 
form  of  a  cone  with  its  apex  at  the  lower  limit  of  denuda- 
tion of  the  femur.  The  thigh  is  thus  removed,  and  after 
ligating  all  visible  vessels  with  catgut  and  excising  about 
an  inch  of  the  exposed  sciatic  nerve  the  tourniquet  is 
loosened  from  the  posterior  flap  first  and  then  the  anterior. 
When  the  hemorrhage  has  been  entirely  checked  the 
wound  is  closed  with  interrupted  sutures  and  dressed  anti- 
septically,  with  drainage  in  its  most  dependent  angles. 

Circular  Method.  The  patient  lying  upon  his  back  with 
his  thigh  overhanging  the  end  of  the  table,  a  circular  in- 
cision is  made  through'the  skiu,  six  inches  below  the  anterior 
superior  spine  of  the  ilium,  the  skin  retracted,  and  the 
muscles  divided  successively  at  higher  levels,  until  the  femur 
is  reached.  The  capsule  is  then  divided  in  front  and  on 
the  sides,  close  to  the  edge  of  the  cotyloid  cavity,  the  head 
of  the  femur  dislocated  forward,  the  knife  passed  behind 
it,  dividing  the  ligamentum  teres,  the  remainder  of  the  cap- 
sule, and  the  muscles  attached  to  the  neck  and  trochanter. 


PART  IV. 

EXCISION  OF  JOINTS  AND  BONES. 


Excision  of  a  joint  may  be  (1)  complete  or  (2)  partial. 
In  the  former  case  the  articular  ends  of  all  the  bones  com- 
posing it  are  removed ;  in  the  latter,  one  or  more  are  re- 
tained. Again,  partial  excision  may  consist  of  (1)  partial 
or  (2)  total  resection  of  the  articular  end  of  one  of  the 
members  of  the  joint.  The  former  is  often  unadvisable  ; 
the  latter,  to  which  Oilier1  has  given  the  name  of  semi- 
articular  resection,  has  given  good  results  in  traumatic 
cases,  and  of  late  also,  under  antiseptic  treatment,  in  tuber- 
culous affections  when  the  disease  is  still  restricted  to  a  por- 
tion of  the  bone  and  capsule. 

Excision  of  a  bone  may  be  total  or  partial,  and,  in  the 
case  of  the  long  bones,  with  or  without  either  or  both  epi- 
physes. 

The  term  resection  is  often  employed  as  a  synonym  of 
excision.  In  the  narrower  sense  it  refers  to  the  removal  of 
a  portion  of  a  bone,  including,  however,  its  entire  thick- 
ness;  thus,  a  joint  is  excised  by  the  resection  of  the  bones 
composing  it. 

Joints  are  excised  on  account  of  injury,  disease,  or  an- 
chylosis in  a  faulty  position;  and  with  the  object  of  obtain- 
ing a  movable  joint,  as  in  the  upper  extremity,  or  anchy- 
losis, as  at  the  knee  and  ankle.  The  operative  procedures 
may  vary  with  these  causes  and  these  objects.  Thus,  when 
anchylosis  is  sought  for,  the  division  of  the  muscles  and 
tendons  about  the  joint  is  of  no  special  moment ;  but  if  the 
joint  is  to  be  re-established,  the  muscles  which  control  its 
movements  must  not  be  disabled.     In  any  case  the  main 

1  CoDgrts  Medical  de  Prance,  4th  session,  1872,  p.  224,  and  Bull,  de  la  Soc.  de 
Cbirnrgle,  L878. 


EXCISION  OF  JOINTS  AND  BONES.  125 

bloodvessels  and  nerves  must  be  respected ;  the  incisions, 
whenever  practicable,  should  be  parallel  to  the  long  axis  of 
the  limb;  and  when  it  is  necessary  to  divide  a  tendon  or 
muscle,  the  line  of  section  should  be  oblique  rather  than 
transverse,  so  as  to  favor  reunion. 

The  incisions  should  be  sufficiently  free  to  allow  the  bone 
to  be  thoroughly  inspected  with  a  view  to  the  removal  of 
all  the  diseased  portion.  It  is  better  to  make  a  clean  divi- 
sion with  the  saw  than  to  remove  the  bone  piecemeal,  but 
the  use  of  the  gouge  is  proper  for  the  removal  of  small 
circumscribed  areas  of  disease  found  upon  the  surfaces  of 
section,  and  even  very  extensively  in  the  young,  as  a  sub- 
stitute for  a  formal  excision  in  order  not  to  diminish  the 
subsequent  growth  of  the  limb  by  the  destruction  or  removal 
of  the  epiphyseal  eartilage. 

The  synovial  membrane  in  traumatic  and  non-tuberculous 
suppurative  cases  does  not  require  special  attention ;  in 
tuberculous  cases  and  when  much  thickened  it  should  be 
cut  or  scraped  away  so  as  to  remove  such  foci  of  infection 
as  may  exist  within  its  walls  or  in  the  fungous  granulations 
on  its  surface.  When  anchylosis  is  sought  for,  as  at  the 
knee,  it  is  prudent  to  dissect  out  the  sac  entirely.  If  any 
portion  is  necessarily  left,  the  destruction  of  the  foci  should 
be  sought  by  thorough  scraping,  washing  with  a  solution  of 
chloride  of  zinc,  1  to  30  or  40,  or  of  corrosive  sublimate, 
1  to  1000,  or  by  the  actual  cautery. 

The  propriety  of  retaining  the  periosteum  is  still  a  sub- 
ject of  discussion,  and  one  in  which  the  decision  will  prob- 
ably vary  with  the  articulation  and  the  circumstances  of 
the  case.  Certain  facts  have,  however,  been  already  estab- 
lished. Its  retention  is  a  safeguard  against  injury  to 
neighboring  tissues  during  the  operation ;  after  excision  of 
a  boue  it  gives  firmness  to  the  cicatrix,  diminishes  the 
shortening  of  the  limb,  and  insures  the  proper  attachment 
of  the  muscles;  and  in  the  case  of  an  articulation,  if  its 
relations  with  the  capsule  are  maintained  (periosteo-capsu- 
lar  excision),  it  favors  the  reproduction  of  the  joint  with 
articular  cartilages  aud  ligamentary  support.  On  the  other 
hand,  the  reproduction  of  bone  is  not  always  desirable,  and 
may  be  excessive  or  irregular,  unduly  limiting  the  motions 
of  the  joint,  or  even  causing  anchylosis ;  aud,  finally,  the 


126  OPERATIVE  SURGERY. 

bruising  received  by  the  periosteum  during  the  operation 
may  cause  it  to  slough,  or  the  reproduction  of  bone  may 
fail  entirely. 

Von  Langenbeck1  has  shown  that  in  excision  of  the 
shoulder -joint  it  is  of  the  utmost  importance  to  preserve 
the  relations  of  the  periosteum,  the  capsule,  and  the  tendons 
of  the  capsular  muscles,  but  in  all  other  joints,  except  per- 
haps the  hip,  the  importance  is  not  so  great  or,  at  least,  so 
well  established.  Complete  restoration  of  the  shoulder- 
joint  and  re-establishment  of  the  control  of  the  muscles  over 
it  have  never  been  accomplished  except  by  the  subperiosteal 
method.  The  periosteum  can  be  removed  without  difficulty 
except  when  it  is  actively  inflamed;  its  connection  with  the 
bone  is  very  slight  in  cases  of  chronic  osteitis  and  synovitis. 
The  tendons,  on  the  other  hand,  are  so  firmly  attached  to 
the  bone  that  the  elevator,  or  rugine,  is  sometimes  insuffi- 
cient to  remove  them  properly,  and  the  knife  must  then 
be  used,  its  edge  being  kept  as  close  as  possible  to  the 
bone.  Von  Langenbeck  goes  so  far  as  to  say  that  the  suc- 
cess of  a  periosteo-capsular  excision  depends  in  great  part 
upon  the  proper  alternation  in  the  use  of  the  knife  and 
elevator. 

Vogt  aud  Kcenig  strongly  recommend  that,  instead  of 
separating  the  tendons  and  ligaments  from  the  bone,  the 
latter  should  be  cut  through  with  a  chisel  so  as  to  leave  a 
shell  attached  to  the  soft  parts.  In  children,  where  the 
epiphyses  are  still  cartilaginous,  this  section  can  be  made 
with  the  knife. 

Excision  of  single  bones  may  be  required  on  account  of 
injury  or  disease.  The  latter  is  by  far  the  most  common 
cause,  and  its  most  common  examples  are  caries  of  the 
small  spongy  bones  and  necrosis  of  the  long  ones,  due  to 
acute  osteomyelitis  or  periostitis.  The  incisions  should  be 
made  from  the  side  where  the  coverings  of  the  bone  are 
fewest  and  of  least  importance;  the  periosteum  should  be 
left  behind,  and  all  the  diseased  bone  should  be  removed. 
When  the  entire  shaft  of  the  bone  has  become  necrotic,  it 
must  be  divided  with  the  chain-saw  or  cutting-pliers,  and 
each  piece  pulled  or  cut  away  from  its  epiphysis. 

1  Arcliiv  liir  kliniselic  Chliurgiei  vol.  xvi. 


EXCISION  OF  JOINTS  AND  BONES.  127 

In  cutting  down  upon  carious  bone  or  a  sequestrum  it  is 
well  to  keep  a  probe  iu  the  sinus  leading  to  it,  as  it  is  some- 
times difficult  to  find  the  hole  in  the  bone  after  the  blood 
has  begun  to  flow. 


MAJOR  ARTICULATIONS. 
EXCISION   OF   THE   SHOULDER-JOINT. 

As  formerly  performed,  excision  of  the  shoulder-joint  was 
an  operation  the  results  of  which,  to  quote  Holmes,1  were 
"  probably  inferior — certainly  not  superior — to  those  of 
natural  anchylosis."  If  anchylosis  did  not  follow,  the  joint 
was  loose,  under  slight  control,  and,  at  the  best,  could  not 
be  raised  above  the  horizontal  line.  Oilier2  and  Von  Lan- 
genbeck,3  however,  have  shown  that  the  periosteo-capsular 
method  furnishes  a  much  larger  measure  of  success.  In  a 
case  operated  upon  by  the  former,  where  four  inches  of  the 
humerus  were  removed,  the  ultimate  shortening  was  only 
half  an  inch,  and  the  motions  were  quite  full ;  and  the 
latter  reports  several  cases  in  which  the  arm  could  be  raised 
to  the  vertical  line,  and  the  control  of  the  limb  was  perfect. 
In  all  of  Von  Langenbeck's  cases  the  operation  was  under- 
taken on  account  of  gunshot-injury. 

As  the  capsular  muscles  are  attached  to  the  greater  and 
lesser  tuberosities,  the  capsule  and  periosteum  must  be 
divided  between  these  two  bony  prominences — that  is,  in 
the  direction  of  and  near  to  the  tendon  of  the  long  head  of 
the  biceps.  An  anterior  incision  beginning  at  the  acromio- 
coracoid  triangle  is  the  best  one  for  this  purpose,  and  has, 
moreover,  the  advantage  of  sparing  the  posterior  circumflex 
artery  and  the  nerve.  The  cephalic  vein  lies  in  the  groove 
between  the  deltoid  and  pectoral  muscles,  and  is  avoided 
by  making  the  incision  incline  outward.  When  the  soft 
parts  are  much  thickened  and  consolidated,  this  incision 
needs  to  be  supplemented  by  a  short  transverse  one  (Fig. 

1  Surgery,  its  Principles  and  Practice,  p.  929.    Lea,  Phila.,  1876. 

2  Traite  de  la  Regeneration  des  Os,  and  des  Resections  des  Grandes  Articula- 
tions.   1867. 

3  Archiv  fur  klinische  Chirargie,  1874,  vol.  xvi. 


128  OPERATIVE  SURGERY. 

51,  B)  running  outward  from  its  upper  end  parallel  to  and 
just  below  the  edge  of  the  acromion,  dividing  the  fibres  of 
the  deltoid  transversely  in  its  course;  sometimes  the  condi- 
tion of  the  parts  is  such,  and  the  sinuses  so  placed,  that  a 

Fig.  51. 


Excision  of  the  shoulder  (Oilier).    A.  Regular  incision.    B.  Supplementary. 

large  external  flap,  with  its  base  directed  upward,  has  to 
be  made  by  a  triangular  or  curved  incision,  and  raised  up 
so  as  freely  to  expose  the  outer  aspect  of  the  head  of  the 
humerus.  In  any  case  the  trunk  of  the  posterior  circumflex 
artery  should  be  spared.  It  is  imbedded  in  loose  cellular 
tissue,  and  when  cut  may  retract  so  far  that  a  ligature  can- 
not easily  be  placed  upon  it. 

The  condition  of  the  glenoid  cavity  seems  to  affect  the 
prognosis  seriously.  In  eight  fatal  cases  collected  by 
Hodges,1  it  had  been  interfered  with  in  all  but  one.  Con- 
sequently it  should  not  be  touched  unless  actually  diseased, 
and  the  interference  should,  if  possible,  be  limited  to  the 
use  of  the  gouge. 

Spence  makes  a  counter-opening  behind  for  drainage, 
but  this  seems  to  be  unnecessary. 

Operation  (Oilier).  Fig.  51.  The  arm  is  addueted  and 
rotated  inward.  The  point  of  the  knife  is  entered  at  the 
beak  of  the  coracoid  process,  and  carried  four  inches  down- 

1  Excision  of  Joints,  Boston,  1801. 


EXCISION  OF  JOINTS  AND  BONES.  129 

ward  and  outward  in  the  general  direction  of  the  fibres  of 
the  deltoid,  or  as  much  further  as  may  be  necessary.  The 
incision  thus  made  will  be  external  to  the  inner  border  of 
the  deltoid,  and  should  comprise  all  the  tissues  down  to  the 
bone. 

The  edges  of  the  wound  are  held  apart  with  retractors, 
and  the  capsule  and  periosteum  are  divided  along  the  outer 
edge  of  the  tendon  of  the  long  head  of  the  biceps  and  the 
bicipital  groove  to  the  full  extent  of  the  external  incision. 
The  outer  edge  of  the  incision  is  raised,  and  the  periosteum, 
together  with  the  capsule  and  tendons  of  the  muscles  inserted 
upon  the  greater  tuberosity,  is  carefully  detached  with  the 
elevator  aud  knife,  while  an  assistant  rotates  the  arm  inward 
to  increase  the  extent  of  aud  facilitate  the  dissection. 

The  tendon  of  the  biceps  is  then  raised  from  its  groove 
aud  held  out  of  the  way,  the  arm  rotated  outward,  and 
the  periosteum,  capsule,  and  tendon  of  the  subscapulars 
dissected  off  in  the  same  way  on  the  inner  side. 

The  head  of  the  humerus  is  then  dislocated  forward,  the 
posterior  attachments  of  the  capsule  separated  with  the 
elevator  or  knife,  the  periosteum  peeled  off  the  posterior 
face  of  the  neck  and  shaft  of  the  humerus,  and  the  bone 
sawn  through  transversely  with  an  ordinary  or  a  chain- 
saw. 

If  the  articular  surface  of  the  glenoid  cavity  is  affected, 
it  must  be  scraped;  if  the  bone  itself  is  diseased,  it  should 
be  gouged  out  until  healthy  bleeding  bone  is  reached,  or 
the  neck  may  be  cut  through  with  strong  cutting-pliers  after 
removal  of  its  periosteum. 

Von  Langenbeck's  method  differs  slightly  from  the  above. 
He  begins  his  incision  at  the  anterior  border  of  the  acro- 
mion just  outside  of  the  acromio-clavicular  junction,  and 
carries  it  directly  downward,  the  arm  being  so  held  as  to 
bring  the  outer  condyle  of  the  humerus  in  front.  This 
sacrifices  the  inner  fibres  of  the  deltoid  by  severing  their 
nerves.  He  carries  the  incision  through  the  muscle  down 
to  the  capsule  and  bone,  then  raises  with  pronged  forceps 
the  sheath  of  the  tendon  of  the  biceps,  which  presents  in 
the  line  of  the  incisiou,  aud  opens  it  carefully  from  without 
inward.     As  soon  as  the  shining  tendon  is  seen  he  slits 


130  OPERATIVE  SUBGEBY. 

the  sheath  throughout  the  entire  length  of  the  incision, 
opening  the  capsule  quite  up  to  the  acromion,  and  exposing 
the  articular  end  of  the  humerus  with  the  tendon  lying 
upon  it. 

He  then  raises  the  periosteum  on  the  inner  side  until  the 
lesser  tuberosity  is  reached,  lays  aside  the  elevator,  and 
peels  off  the  tendon  of  the  subscapular  with  knife  and 
pronged  forceps,  taking  the  greatest  pains  to  maintain  its 
relations  with  the  capsule  and  periosteum.  After  this  dis- 
section has  been  carried  as  far  as  possible  on  the  inner  side, 
he  lifts  the  tendon  of  the  biceps  from  its  sheath,  carries  it 
inward,  drops  it  into  the  joint,  and  denudes  the  bone  on 
the  outer  side  with  the  same  precautions,  using  the  knife 
instead  of  the  elevator  to  detach  the  capsule,  tendons,  and 
ligaments.     The  rest  of  the  operation  as  above. 

If  only  the  articular  head  of  the  bone  is  to  be  resected, 
near  the  upper  end  of  the  tuberosities,  there  is  no  perios- 
teum to  be  removed.  The  ligamentous  and  muscular  at- 
tachments are  approached  from  within  the  joint,  and  the 
bone  divided  with  the  chain  or  keyhole  saw,  without  rais- 
ing it  from  its  place. 

By  a  Transverse  Incision.  (Nelaton,  Perrin.)  A  trans- 
verse incision  three  and  a  half  or  four  inches  long  is  made 
parallel  to  and  half  an  inch  below  the  edge  of  the  acromion, 
beginning  in  front  between  it  and  the  coracoid  process.  The 
fibres  of  the  deltoid  are  divided  close  to  the  acromion,  and 
by  their  retraction  expose  the  capsule  largely. 

The  capsule  is  divided  along  the  outer  edge  of  the  tendon 
of  the  biceps,  and  then  transversely  in  the  direction  of  the 
external  wound ;  the  bone  is  approached  and  denuded 
through  this  opening,  and  the  operation  completed  as  before. 

The  vessels  and  nerves  are  well  protected  by  this  method, 
but  it  is  very  difficult  of  execution. 

Excision  of  the  Head  of  the  Scapula.  When  the  disease 
is  confined  to  the  glenoid  cavity  and  the  neck  of  the  scapula, 
the  affected  parts  can  be  removed  by  a  longitudinal  pos- 
terior incision  extending  from  the  base  of  the  acromion  to 
the  fold  of  the  axilla. 


EXCISION  OF  JOINTS  AND  BONES.  131 


EXCISION    OF   THE    ELBOW- JOINT. 

Partial  excision  of  the  elbow-joint  for  disease,  even  when 
the  portions  left  behind  are  entirely  healthy,  is  more  dan- 
gerous and  gives  as  a  rule  less  satisfactory  results  than  com- 
plete excisiou.  The  humerus  should  be  sawn  through  at  or 
just  above  the  epicondyles,  the  ulna  at  the  base  of  the 
corouoid  process,  and  the  radius  through  its  neck.  The 
extent  of  the  disease  may  make  it  uecessary  to  surpass  these 
limits,  but  the  result  will  then  be  less  perfect,  and  in  any 
case  every  effort  should  be  made  to  preserve  the  continuity 
between  the  periosteum  and  the  tendons  of  the  brachialis 
anticus  and  biceps  so  as  to  provide  for  future  flexion  of  the 
forearm.  An  exception  to  the  rule  of  total  excision  may  be 
found  in  the  preservation  under  some  circumstances  of  all 
the  olecranon  except  its  articular  surface ;  the  joint  thus 
obtained  is  firmer,  and  active  extension  more  powerful. 

Reproduction  of  bone  takes  place  less  completely  at  the 
elbow-joint  than  at  any  other  of  the  major  articulations,  and 
consequently  the  greater  the  amount  removed  the  greater 
the  danger  of  the  formation  of  an  imperfect,  loose,  and  in- 
efficient joint,  even  when  the  subperiosteal  method  has  been 
thoroughly  carried  out.  Von  Langenbeck1  removed  four 
and  a  half  inches  of  the  humerus  and  two  inches  of  the 
ulna  subperiosteally  in  a  case  of  gunshot-injury,  and  says 
the  result  was  the  worst  he  ever  saw,  the  connection  be- 
tween the  arm  and  forearm  being  so  very  loose  that  the 
patient  was  obliged  to  use  a  supporting  brace,  by  the  aid  of 
which  he  was  able  nevertheless  to  make  excellent  use  of  his 
hand.  Ordinarily  anchylosis  is  to  be  preferred  to  a  very 
loose  joint. 

In  cases  of  gunshot-injury  Von  Langenbeck  and  Oilier 
remove  as  little  as  possible,  making  a  partial  (semi-articular) 
excision  when  either  the  humerus  or  the  bones  of  the  fore- 
arm alone  are  injured.  The  English  authors  think  the 
danger  in  cases  of  excision  for  disease  is  rather  of  removing 
too  little  than  too  much,  and  recommend  that  the  humerus 
be  sawn  through  above  the  condyles. 

As  the  joint  is  covered  anteriorly  with  soft  parts,  among 

1  Loc.  cit.,  p.  443. 


132  OPERATIVE  SURGERY. 

which  lie  nearly  all  the  principal  arteries  and  nerves,  and 
is  almost  subcutaneous  posteriorly,  it  must  be  approached 
from  the  latter  side,  and  the  incisions  must  be  made  with 
especial  reference  to  the  safety  of  the  ulnar  nerve,  where  it 
runs  between  the  olecranon  and  the  epitrochlea.  The  orig- 
inal method,  and  the  one  used  almost  exclusively  for  many 
years,  was  the  H-incision,  composed  of  two  longitudinal  in- 
cisions connected  midway  by  a  transverse  one  crossing  the 
tip  of  the  olecranon.  It  has  the  disadvantage  of  dividing 
the  ulnar  nerve  or  exposing  it  in  the  wound  if  suppuration 
occurs,  and,  having  been  superseded  by  less  complicated 
ones,  does  not  need  to  be  described. 

Although  excellent  joints  have  been  obtained  by  the  old 
operations  the  preference  should  be  given  to  the  modern 
subperiosteal  method,  not  only  on  account  of  the  greater 
certainty  of  the  re-establishment  of  a  useful  limb,  but  also 
because  the  danger  of  diffuse  inflammation  and  purulent 
infiltration  is  much  less  when  it  is  employed.  These  dan- 
gers are  greater  at  the  elbow  than  at  any  other  joint,  except 
the  hip,  aud  secondary  amputation  is  more  frequently  re- 
quired. 

The  other  methods  have  been  devised  with  the  view  of 
sparing  the  nerve,  preserving  the  attachment  of  the  triceps 
and  the  continuity  of  the  lateral  ligaments  with  the  perios- 
teum, and  facilitating  the  operation.  Although  the  central 
longitudinal  incision  has  been  extensively  used  the  prefer- 
ence seems  now  to  be  due  to  methods  of  approach  from  the 
radial  side,  such  as  Ollier's,  Nekton's,  and  Hueter's. 

Central  Longitudinal  Incision.  Fig.  52,  A.  (Von  Lan- 
genbeck.)  The  forearm  being  slightly  flexed,  a  longitudinal 
incision  3£  inches  long  is  made  a  little  to  the  inner  side  of 
the  median  line  of  the  triceps  and  ulna,  and  carried  down 
to  the  bone.  The  inner  edge  of  the  divided  periosteum  is 
raised  from  the  ulna,  the  corresponding  half  of  the  tendon 
of  the  triceps  detached  with  it,  and  the  dissection  continued 
toward  the  internal  condyle,  the  knife  being  kept  constantly 
against  the  bone,  and  the  flexion  of  the  arm  increased  as 
tiie  dissection  advances.  As  the  epitrochlea  is  approached 
the  greatest  care  is  needed  to  preserve  the  connection  be- 
tween the  periosteum,  the  muscular  attachments,  and  the 


EXCISION  OF  JOINTS  AND  BONES. 


internal  lateral  ligament,  and  it  may  be  necessary  to  pro- 
long the  first  incision  upward  so  as  to  get  more  room. 

After  the  inner  half  of  the  joint  has  thus  been  laid  open 
and  the  epitrochlea  bared,  the  soft  parts 
are  replaced  and  a  similar  dissection 
made  upon  the  outer  side  with  the  same         |    B  \      A      \ 
precautions. 

The  humerus  is  then  dislocated  back- 
ward through  the  wound  and  sawn 
through  at,  or  as  near  as  possible  to,  the 
epicondyles,  according  to  the  lesion.  If 
the  condition  of  the  soft  parts  does  not 
allow  of  this  projection  of  the  humerus, 
the  chain  or  keyhole  saw  must  be  used. 

The  ulna  is  then  cleaned  circularly  as 
far  as  necessary  and  sawn  through,  and 
the  head  of  the  radius  removed  with 
the  saw  or  cutting-pliers. 


Excision  of  the  elbow- 
joint.  A.  Von  Langen- 
beck.    B.  Oilier. 


Ollier's  Method.1  (Fig.  52,  B.)  The 
forearm  is  slightly  flexed,  and  an  in- 
cision is  commenced  two  inches  above 
the  tip  of  the  olecranon  on  the  outer 
side  of  the  arm  at  the  interstice  between  the  triceps  and 
supinator  longus.  This  incision,  involving  the  skin  only, 
is  carried  downward  to  the  epicondyle,  thence  downward 
and  inward  in  the  line  of  the  upper  border  of  the  anconseus 
to  the  olecranon,  and  thence,  the  point  of  the  knife  touch- 
ing the  bone,  directly  downward  along  the  inner  side  of 
the  posterior  aspect  of  the  ulna  for  one  or  two  inches. 

The  fascia  is  then  divided  in  the  line  of  the  incision,  and 
the  interstice  between  the  triceps  on  one  side  and  the  supi- 
nator longus,  radial  extensor,  and  anconseus  on  the  other, 
followed  down  to  the  capsule  and  bone.  The  capsule  is 
opened,  and  the  humerus  denuded  on  its  anterior  and  pos- 
terior faces  as  far  inward  as  possible,  care  being  taken  to 
maintain  the  relations  of  the  muscular  and  ligamentary 
attachments. 

The  tendon  of  the  triceps  and  the  periosteum  of  the  ulna 


1  Traite  de  la  Regeneration  des  Os,  p.  340. 
7 


134 


OPERATIVE  SURGERY. 


are  next  detached,  and  in  separating  the  former  it  is  better 
to  begin  inside  the  joint  at  the  free  edge  of  the  olecranon. 

The  denudation  of  the  external  condyle  and  tuberosity  of 
the  humerus  is  then  completed,  and  the  external  lateral 
ligament  entirely  detached,  the  forearm  flexed  on  its  inner 
side,  and  the  end  of  the  humerus  dislocated  outward  into 
the  wound,  thus  rendering  the  difficult  dissection  of  the 
projecting  epitrochlea  easier.  When 
fig.  53.  this   latter  has  been   completed,   the 

periosteum  of  the  humerus  is  raised 
circularly  to  the  proper  height,  and 
the  bone  sawn  through.  The  head 
of  the  radius  is  then  removed,  the 
denudation  of  the  ulna  completed, 
and  the  bone  sawn  through  perpen- 
dicularly to  its  axis. 

Nelaton's  Method.  (Fig.  53,  A.) 
A  longitudinal  incision  is  begun  on 
the  outer  border  of  the  humerus  be- 
tween the  triceps  and  supinator  longus, 
1|  inches  above  the  end  of  the  olecra- 
non, and  carried  downward  for  a  dis- 
tanceof  3  inches.  A  transverse  incision 
cutting  through  to  the  bone  is  next 
made  from  the  lower  end  of  the  first, 
across  the  ulna  to  its  inner  border. 

The  triangular  flap  thus  formed, 
including  the  periosteum  of  the  ulna, 
is  dissected  up,  the  external  lateral  and  orbicular  ligaments 
divided,  and  the  head  of  the  radius  removed.  The  tendon 
of  the  triceps  is  detached  and  the  denudation  of  the  ulna 
completed. 

The  ulna  is  projected  through  the  incision  by  bending 
the  forearm  toward  its  inner  side,  and  is  sawn  off. 

The  humerus  is  then  easily  turned  out  through  the  in- 
cision, denuded  from  below  upward  with  the  usual  precau- 
tions, and  sawn  off  at  the  desired  height. 

Long  Radial  Incision  (Hueter).1  (Fig.  53,  B  and  C.) 
A  preliminary  longitudinal  incision,  half  an  inch  long,  is 


I    !    \    l    \ 

Excision  of  the  elbow- 
joint.  A.  Nelaton.  B,  C. 
Hueter. 


1  DeutBCbe  ZeitSChrift  i'iirChirurgie,  2d  vol.,  p.  G8. 


EXCISION  OF  JOINTS  AND  BONES. 


135 


first  made  directly  down  upon  the  tip  of  the  epitrochlea,  or 
rather  on  its  anterior  side,  so  as  more  surely  to  avoid  the 
ulnar  nerve  which  lies  close  behind  it,  and  the  muscular 
attachments  and  the  internal  lateral  ligament  are  separated 
by  cutting  around  this  prominence. 

The  main  incision  is  then  made  by  entering  the  knife 
above  the  point  of  the  external  epicondyle  and  carrying  it 
straight  down  over  it,  thus  opening  the  joint  and  exposing 
the  head  of  the  radius  by  dividing  the  external  lateral  liga- 
ment longitudinally  and  the  orbicular  ligament  transversely. 
The  head  of  the  radius  is  then  removed  after  sawing  through 
its  neck. 

The  operator  then  passes  his  left  forefinger  through  the 
wound,  first  to  the  anterior  surface  of  the  humerus  to  make 
the  capsule  tense,  and  guide  the  detachment  of  it  and  the 
periosteum,  and  then  along  the  posterior  surface  under  the 
tendon  of  the  triceps  with  the  same  object. 

It  is  not  necessary  to  carry  this  dissection  very  far  to- 
ward the  inner  side,  because  by  dislocating  the  ulna  forci- 
bly inward  the  end  of  the  humerus  can 
be  made  to  project  through  the  radial 
incision,  and  then  its  denudation  can 
be  easily  and  safely  completed,  and  the 
bone  sawn  through. 

The  end  of  the  olecranon  is  then 
brought  into  the  centre  of  the  incision, 
and  the  separation  of  the  triceps  be- 
gun at  the  upper  free  edge  of  the  pro- 
cess with  vigorous  short  cuts  into  the 
substance  of  the  bone,  so  that  it  is,  as 
it  were,  peeled  out  of  its  tendinous 
envelope.  When  the  proper  point  is 
reached  the  bone  is  sawn  through. 


Fig 


Osteoplastic  method. 

A.  By  external  incision. 

B.  VonMosetig-Moorhof. 


Osteoplastic  Method.  (Fig.  54.)  This 
operation,  characterized  by  primary 
division  of  the  olecranon  and  its  re- 
union at  the  close  of  the  operation,  was 
proposed  by  Von  JBruus,  and  was  at  first  deemed  applica- 
ble to  old,  irreducible,  and  to  fresh  compound  dislocations. 
Its  use  has  been  extended  to  operations  for  foreign  bodies 


136  OPERATIVE  SURGERY. 

in  the  joint,  for  anchylosis,  and  finally  to  those  for  fungous 
arthritis. 

The  procedure  recommended  by  Von  Mosetig-Moorhof 
begins  by  a  transverse  incision  running  from  the  lowest 
point  of  the  external  condyle  across  the  olecranon  to  its 
inner  side,  thence  upward  alongside  the  olecranon  to  a  point 
one  inch  above  its  tip.  The  ulnar  nerve  is  then  dissected 
out  and  drawn  aside,  aud  the  olecranon  divided  with  saw 
and  chisel  in  the  line  of  the  first  part  of  the  incision.  The 
flap  is  then  drawn  aside,  the  humerus  cleared  and  sawn  off 
below  the  epicondyles,  the  head  of  the  radius  removed,  and 
the  olecranon  scraped  and  reunited  with  a  silver  suture. 

I  think  this  exposure  of  the  ulnar  nerve  is  unnecessary 
and  objectionable,  and  have  modified  the  operation  by  using 
the  lower  two-thirds  of  Oilier' s  incision  and  making  a  second 
transverse  one  from  the  lower  end  of  the  first  across  the  base 
of  the  olecranon,  and  sawing  the  latter  through  in  this  line, 
but  somewhat  obliquely  from  below  upward,  into  the  joint. 
The  joint  was  then  further  opened  through  the  lateral  in- 
cision, the  external  condyle  denuded,  and  the  flap,  including 
the  upper  part  of  the  olecranon,  turned  upward  and  inward. 
This  exposed  the  joint  freely,  aud  the  humerus  was  then 
readily  denuded  and  sawn  off  through  the  epicondyles.  The 
radius  was  then  protruded  and  sawn  through  at  the  neck, 
the  olecranon  thoroughly  scraped,  removing  most  of  the 
coronoid  process,  and  the  capsule  dissected  out.  As  the 
scraping  of  the  olecranon  had  left  its  sigmoid  cavity  much 
too  large,  I  removed  a  slice  one  centimetre  thick  along  the 
line  of  its  original  section  to  shorten  it,  and  then  wired  the 
pieces  together.  The  result  was  very  good,  and  active  ex- 
tension more  powerful  than  in  any  other  case  I  have  seen. 

Bilateral  Incidons.  Vogt1  speaks  highly  of  a  method 
by  which  he  accomplishes  the  same  result  without  division 
of  the  olecranon.  His  incision  begins  above  the  external 
condyle  and  is  carried  well  below  the  head  of  the  radius, 
dividing  the  orbicular  ligament ;  then  he  removes  the  peri- 
osteum from  the  radius  and  divides  it  with  saw  or  chisel 
just  above   its  tuberosity,  draws  aside   the  edges  of  the 

1  Centralblatt  fur  Chlrurgie,  1882,  p.  555. 


EXCISION  OF  JOINTS  AND  BONES.  137 

wound,  and  explores  the  joint.  If  it  is  extensively  dis- 
eased, he  makes  a  second  incision  on  the  inner  side,  begin- 
ning above  and  a  little  behind  the  epitrochlea  and  extend- 
ing about  three  inches  downward,  then  with  a  chisel  cuts 
away  the  attachments  of  the  extensor  and  flexor  muscles 
from  the  condyles,  leaving  a  shell  of  bone  attached  to 
them,  draws  aside  the  soft  parts,  divides  the  capsule,  raises 
the  periosteum  from  the  humerus,  and  saws  off  the  end  of 
the  latter.  Then,  if  necessary,  he  scrapes  away  the  surface 
of  the  olecranon. 

Partial  Excision.  Ollier's  and  Hueter's  methods  are 
especially  applicable  to  that  form  of  semiarticular  excision 
in  which  only  the  lower  end  of  the  humerus  is  resected. 
Nelaton's  or  Von  Langenbeck's,  or  the  lower  part  of 
Ollier's,  can  be  used  for  the  removal  of  the  ends  of  the 
ulua  and  radius. 


EXCISION    OF   ANCHYLOSED    ELBOW. 

When  there  is  anchylosis  of  the  joint,  Von  Langenbeck's 
incision  can  be  used,  and  the  ulna  divided  with  a  chain- 
saw  or  chisel  after  it  has  been  denuded.  The  detachment 
of  the  capsule  and  periosteum  is  then  proceeded  with  up- 
ward, and  the  lower  end  of  the  humerus,  with  the  attached 
ends  of  the  bones  of  the  forearm,  projected  through  the 
wound  and  sawn  off. 

Or  the  osteoplastic  or  either  of  the  two  following  methods 
may  be  employed : 

Excision  of  Anehylosed  Elbow  (Oilier).  An  incision 
two  and  a  half  inches  long  is  first  made  on  the  outer  and 
posterior  side  of  the  limb  and  carried  through  to  the  bone, 
its  centre  being  on  a  level  with  the  tip  of  the  olecrauon. 
A  second  incision  one  and  a  half  inches  long,  involving  the 
skin  only,  is  made  on  the  inner  side  of  the  ulnar  nerve  at 
the  level  of  the  internal  border  of  the  humerus.  The  nerve 
is  found  on  dividing  the  fascia,  is  drawn  aside  together  with 
the  posterior  lip  of  the  wound  with  a  blunt  hook,  and  is 
then  entirely  out  of  the  way  of  injury. 


138  OPERATIVE  SURGERY. 

The  lips  of  the  two  wounds  are  separated,  the  periosteum 
detached,  a  narrow  saw  passed  under  the  triceps,  and  the 
humerus  sawn  nearly  through  from  behind  forward,  leaviug 
a  thin  shell  of  bone  in  front,  which  is  then  broken.  The 
conditions  are  now  those  of  a  movable  joint,  and  more  or 
less  of  the  lower  fragment  or  of  each  fragment  is  removed, 
according  to  the  condition  of  the  bone.  The  triceps  should 
be  detached  before  the  olecranon  is  divided. 

Excision  of  Anchylosed  Elbow  (P.  Heron  Watson1).  This 
method  is  intended  only  for  the  removal  of  the  articular 
end  of  the  humerus,  iu  cases  of  more  or  less  complete  auchy- 
losis  following  injury.  The  advantages  claimed  for  it  are 
that  it  leaves  the  attachments  of  the  triceps  and  brachialis 
anticus  undisturbed,  and  limits  the  area  of  the  operation 
almost  exclusively  to  within  the  capsular  ligament,  and 
thereby  seems  to  secure  a  more  speedy  healing  of  the  wouud. 
Watson  has  used  it  in  six  cases,  in  all  of  which  the  results 
were  satisfactory. 

1.  A  linear  incision  is  made  over  the  ulnar  nerve  at  the 
inner  side  of  the  olecranon.  2.  The  nerve  is  carefully 
turned  over  the  inner  condyle.  3.  A  probe-pointed  bis- 
toury is  introduced  into  the  elbow-joint  in  front  of  the 
humerus  and  then  behind  that  bone,  and  carried  upward  so 
as  to  divide  the  upper  capsular  attachments  in  front  and 
behind.  4.  A  pair  of  bone-forceps  are  next  employed  to 
cut  off  the  entire  inuer  condyle  and  trochlea  of  the  humerus 
[from  above  downward],  and  then  introduced  in  the  oppo- 
site direction  [from  below  upward  and  outward],  so  as  to 
detach  the  external  condyle  and  capitellum  of  the  humerus 
from  the  shaft.  5.  The  angular  end  of  the  humerus  is 
turned  out  through  the  incision  and  sawn  off  square.  6. 
The  external  condyle  and  capitellum  are  removed  partly  by 
twisting,  partly  by  dissection,  without  any  division  of  the 
skin  on  the  outer  side  of  the  arm. 

If  there  is  dense  osseous  union  that  cannot  be  overcome 
by  flexion  and  extension  under  chloroform,  the  humerus 
must  be  divided  through  the  condyle  with  bone-pliers,  and 
the  operation  completed  as  above. 


|  Edinburgh  Med.  Joum.,  May,  L878,  p. 


986. 


EXCISION  OF  JOINTS  AND  BONES 


139 


Fig.  55. 


Operative  Reduction  of  Old  Unreduced  Backward  Dislo- 
cation of  the  Elbow.1  The  first  incision  is  made  on  the 
outer  side  (Fig.  55),  beginning  well  up  on  the  supinator 
ridge  and  passing  downward  to 
and  across  the  head  of  the  radius, 
and  then  for  one  or  two  inches 
posteriorly  in  the  interval  between 
the  radius  and  ulna.  Through  this 
the  newly  formed  bone  (Fig.  55, 
A)  on  the  back  of  the  humerus  is 
exposed  and  chiseled  away,  and 
the  outer  aspect  of  the  external 
condyle  freed  by  dividing  its 
fibrous  attachments  to  the  radius 
and  ulna  until  the  capitellum  is 
freely  exposed.  The  sides  of  the 
upper  portion  of  the  wound  are 
then  retracted,  the  olecranon  ex- 
posed, aud  the  sigmoid  cavity 
cleared  of  the  mass  of  fibrous 
tissue  which,  more  or  less,  fills  it 
and  binds  it  to  the  back  of  the 
humerus. 

A  second  incision  is  now  made 
on  the  inner  side.  It  is  about 
four  inches  long  and  slightly 
curved,  with  its  concavity  forward,  and  it  passes  close 
behind  the  internal  epicoudyle  or  its  site  if  it  has  broken 
off  and  is  displaced.  The  ulnar  nerve  is  found  on  dividing 
the  fascia,  and  is  carefully  drawn  forward  over  the  internal 
condyle.  The  fibrous  bands  between  the  condyle  aud  ole- 
cranon are  divided.  If  the  epicondyle  has  been  torn  from 
its  position  and  is  attached  to  the  humerus  higher  up,  it 
must  be  freed  and  brought  back  with  its  attached  internal 
lateral  ligament.  The  division  of  the  soft  parts  must  be  con- 
tinued until  the  trochlear  surface  of  the  humerus  is  freely 
exposed.  If  the  injury  is  of  long  standing,  and  thereby 
the  flexor  muscles  permanently  shortened,  they  must  be 
separated  from  the  internal  condyle  before  reduction  can 


Incision  for  the  operative 
treatment  of  old  unreduced 
dislocation  of  the  elbow. 

A.  Periosteal  bridge  and  new 
tissue  occupying  the  posterior 
surface  of  the  lower  extremity 
of  the  humerus. 


1  Dr.  L.  A.  Rtimson  :  N.  Y.  Med.  Journ.,  Oct.  24,  1891. 


140 


OPERATIVE  SURGERY. 


be  accomplished.     After  the  wound  is  closed  the  arm  is 
dressed  at  right-angles  in  an  immobilization  apparatus. 


EXCISION    OF    THE   WRIST. 


Posteriorly  and  laterally  the  wrist  is  covered  only  with 
skin  and  tendous,  with  no  arteries  or  nerves  of  importance 
except  the  radial  artery,  which  winds  around  the  outer  side 
to  pass  again  through  the  first  metacarpal  space  to  the  pal- 
mar aspect  of  the  hand,  and  form  the  deep  palmar  arch 
just  below  the  bases  of  the  metacarpal  bones.  Between 
the  extensor  tendons  of  the  thumb  and  of  the  forefinger 
exists  a  triaugular  interval,  shown  in  Fig   57,  the  apex  of 

Fig.  56. 


Excision  of  the  wrist,  Lister.  A.  Peep  palmar  arch.  B.  Trapezium,  C.  Articu- 
lar surface  of  the  ulnar.  The  dotted  lines  include  the  amount  removed  in  the 
earlier  operations;  the  unshaded  portions  represent  those  removed  when  the 
disea  e  is  limited  to  the  carpus. 

which  is  directed  upward  and  lies  near  the  middle  of  the 
dorsal  aspect  of  the  epiphysis  of  the  radius.  Within  this 
space  arc  found  only  the  tendons  of  the  long  and  short  ex- 
tensores  carpi  radiales,  with  their  insertions  into  the  second 
and  third   metacarpals,  and  as  experience  has  shown  that 


EXCISION  OF  JOINTS  AND  BONES.  141 

these  tendons  can  be  detached  or  divided  without  prejudice 
to  the  subsequent  usefulness  of  the  hand,  the  articulation 
can  be  safely  approached  through  this  space. 

The  extensor  tendons  are  lodged  in  deep  grooves  upon 
the  surface  of  the  radius,  from  which  it  is  very  difficult  to 
raise  them  without  opening  their  sheaths,  and  therefore  if  it 
is  necessary  to  take  more  than  a  thin  slice  from  the  bevelled 
end  of  the  bone,  it  should  be  done  with  a  gouge  and  as  a 
late  step  in  the  operation.  In  this  way  it  is  possible  to 
leave  the  tendons  unhurt,  and  even  unseen. 

On  the  inner  side  the  tendon  of  the  extensor  carpi  ulnaris 
covers  the  ulna,  in  front  of  it  passes  the  flexor  carpi  ulnaris 
on  its  way  to  its  insertion  into  the  pisiform  bone  and  the 
base  of  the  fifth  metacarpal.  The  anterior  aspect  is  occu- 
pied by  the  numerous  and  important  flexor  tendons,  the 
median  and  ulnar  nerves,  and  several  arteries  or  arterial 
branches  of  considerable  size.  Toward  the  outer  side  the 
tendon  of  the  flexor  carpi  radialis  passes  through  a  groove 
on  the  surface  of  the  trapezium,  to  be  attached  beyond  the 
base  of  the  second  metacarpal.  An  ulnar  incision  should 
pass  between  the  flexor  and  extensor  carpi  ulnaris  at  the 
anterior  border  of  the  ulna. 

Bilateral  Incisions  (Lister1).  Figs.  57  and  58,  A,  B. 
All  adhesions  are  first  broken  down  by  freely  moving  all 
the  articulations  of  the  hand.  The  radial  incision  is  made 
in  the  situation  indicated  by  the  line  L  L  in  Fig.  57,  or 
Fig.  58,  A.  It  commences  above  at  the  middle  of  the 
dorsal  aspect  of  the  radius  on  a  level  with  the  styloid  pro- 
cess. Thence  it  is  at  first  directed  toward  the  inner  side  of 
the  metacarpophalangeal  articulation  of  the  thumb,  run- 
ning parallel  to  the  tendon  of  the  extensor  secundi  inter- 
nodii ;  on  reaching  the  radial  border  of  the  second  meta- 
carpal bone  it  is  carried  downward  longitudinally  for  half 
the  length  of  the  bone. 

The  soft  parts  on  the  radial  side  of  the  incision  are  next 
detached  from  the  bones  with  the  knife  guarded  by  the 
thumb-nail,  so  as  to  divide  the  tendon  of  the  extensor  carpi 
radialis  longior  at  its  insertion  into  the  base  of  the  second 

1  Lancet,  1865,  p.  335.  slightly  abridged. 
7* 


142 


OPERATIVE  SURGERY. 


metacarpal,  and  raise  it  along  with  that  of  the  extensor 
brevior,  previously  cut  across,  and  the  extensor  secundi  in- 
ternodii,  while  the  radial  artery  is  thrust  somewhat  out- 
ward. The  trapezium  is  then  separated  from  the  rest  of 
the  carpus  by  means  of  cutting-forceps  applied   in  a  line 


Fig.  57. 


J>         G 

Excision  of  the  wrist,  Lister.  A.  The  radial  artery.  B.  Extensor  secundi 
internodii  pollicis.  D.  Ext.  eonim.  digitoruni.  E.  Ext.  min.  dig.  F.  Ext.  prim. 
int.  pol.  G.  Ext.  oss.  met.  poll.  H.  I.  Ext.  carp.  rad.  long,  and  brev.  A'.  Ext. 
carp.  uln.    L,  L.  Line  of  radial  incision. 


with  the  longitudinal  part  of  the  incision.  The  removal  of 
the  trapezium  is  reserved  till  the  rest  of  the  carpus  has 
been  taken  away.  The  soft  parts  on  the  ulnar  side  of  the 
incision  are  now  dissected  up  as  far  as  is  convenient,  the 
extensor  tendons  being  relaxed  by  bending  back  the  hand. 
The  knife  is  next  entered  on  the  inner  side  of  the  arm, 
two  inches  above  the  end  of  the  ulna,  immediately  anterior 
to  the  bone,  and  is  carried  downward  between  it  and  the 
flexor  carpi  ulnaris,  and  on  in  a  straight  line  as  far  as  to 
the  middle  of  the  fifth  metacarpal  bone  at  its  palmar  aspect 
(Fig.  58,  B).  The  dorsal  lip  of  the  incision  is  raised,  and 
the  tendon  of  the  extensor  carpi  ulnaris  cut  at  its  insertion 


EXCISION  OF  JOINTS  AND  BONES.  143 

into  the  fifth  metacarpal,  and  dissected  up  from  its  groove 
in  the  ulna,  care  being  taken  to  avoid  isolating  it  from  the 
integuments,  and  thus  endangeriug  its  vitality.  The  ex- 
tensors of  the  fingers  are  then  readily  separated  from  the 
carpus,  and  the  dorsal  aud  internal  ligaments  divided,  but 
the  connections  of  the  tendons  with  the  radius  are  purposely 
left  undisturbed. 

The  anterior  surface  of  the  ulna  is  then  cleared  by  cut- 
ting toward  the  bone,  so  as  to  avoid  the  artery  and  nerve ; 
the  articulation  of  the  pisiform  is  opened,  if  that  has  not 
been  already  done  in  making  the  incision,  and  the  flexor 
tendons  are  separated  from  the  carpus.  While  this  is  being 
done  the  knife  is  arrested  by  the  process  of  the  unciform 
bone,  which  is  clipped  through  at  its  base  with  pliers.  The 
knife  must  not  be  carried  further  down  the  hand  than  the 
bases  of  the  metacarpal  bones,  so  as  not  to  injure  the  deep 
palmar  arch.  The  anterior  ligament  of  the  wrist-joint  is 
divided,  after  which  the  junction  between  the  carpus  and 
metacarpus  is  severed  with  cutting-pliers,  and  the  carpus 
extracted  through  the  ulnar  incision  by  seizing  it  with 
strong  forceps  and  touching  with  the  knife  any  ligamentous 
connections  that  may  remain  undivided. 

The  hand  being  now  forcibly  everted  the  articular  ends 
of  the  radius  and  ulna  will  protrude  at  the  ulnar  incision. 
If  they  appear  sound  or  only  superficially  affected,  the 
articular  surfaces  only  are  removed.  The  ulna  is  divided 
obliquely  with  a  small  saw,  so  as  to  take  away  the  cartilage- 
covered  rounded  part  over  which  the  radius  sweeps,  while 
the  base  of  the  styloid  process  is  retained.  The  end  of  the 
radius  is  then  cleared  sufficiently  to  allow  a  thin  slice  to  be 
sawn  off  parallel  to  the  general  direction  of  the  inferior 
articular  surface  and  the  articular  facet  on  the  ulnar  side 
of  the  bone  is  clipped  away  with  bone-forceps.  If,  on  the 
other  hand,  the  bones  prove  to  be  deeply  carious,  the  pliers 
or  gouge  must  be  used  with  the  greatest  freedom. 

The  metacarpal  bones  are  next  dealt  with  on  the  same 
principle.  If  sound,  only  the  articular  surfaces  are  clipped 
off. 

The  trapezium  is  next  seized  with  forceps  and  dissected 
out,  so  as  to  avoid  cutting  the  tendon  of  the  flexor  carpi 
radialis,  which  is  firmly  bound  into  the  groove  on  its  palmar 


144 


OPERATIVE  SUROEBY. 


aspect,  the  knife  being  also  kept  close  to  the  bone  elsewhere 
to  preserve  the  radial  artery.  The  articular  end  of  the 
first  metacarpal  is  then  removed.  Lastly,  the  articular 
surface  of  the  pisiform  is  clipped  off,  the  rest  of  the  bone 
beiug  left  if  souud.  The  process  of  the  unciform  is  also 
left  if  sound.  The  radial  wound  may  be  closed  with  sutures, 
but  the  ulnar  one  must  be  kept  open  for  drainage,  and  the 
limb  must  be  bound  upon  a  splint  in  such  a  manner  that 
while  the  wrist  is  firmly  fixed  passive  motion  can  be  given 
regularly  to  the  fingers. 

Radial  Incision  (Oilier).  Fig.  58,  C.  An  incision 
involving  only  the  skin  is  begun  on  the  outer  side  of  the 
wrist,  an  inch  below  the  styloid  process  of  the  radius,  and 


Fig.  58. 


Excision  of  the  wrist.    A.  Lister's  radial  incision.    B.  Lister's  ulnar  incision. 
C.  Oilier.    D.  Von  Langenbeck. 

carried  upward  along  the  outer  border  of  the  bone  for  a 
greater  or  less  distance,  according  to  the  amount  to  be  re- 
moved. A  cutaneous  branch  of  the  radial  nerve  is  exposed 
and  drawn  aside,  the  fascia  divided,  and  the  extensor  ten- 
dons of  the  thumb  recognized.  These  tendons  are  a  guide 
which  is  easily  found.  They  are  superficial,  and  contained 
in  a  separate  groove.  On  opening  the  sheath  and  drawing 
them  aside,  the  insertion  of  the  supinator  longus  is  exposed, 


EXCISION  OF  JOINTS  AND  BONES.  145 

on  the  outer  side  of  which,  and  parallel  to  the  tendoD,  the 
periosteum  of  the  radius  must  then  be  divided. 

Using  a  straight,  sharp  elevator,  the  surgeon  next  de- 
taches the  tendon  of  the  supinator,  preserving  its  relations 
with  the  periosteum,  and  then  denudes  the  lower  end  of  the 
radius  inward,  removing  periosteum  and  capsule.  Then, 
bending  the  hand  forcibly  toward  its  inner  side,  he  sepa- 
rates the  remaining  fibrous  attachments  and  dislocates  the 
lower  end  of  the  radius  outward.  The  ulna  can  be  pro- 
truded through  the  same  wound  and  denuded  from  below 
upward,  but  it  is  better  to  make  a  longitudinal  incision  on 
the  inner  side  for  this  purpose. 

The  ends  of  the  radius  and  ulna  are  then  sawn  off,  and 
through  the  gap  thus  left  the  carpal  bones  are  successively 
removed  with  gouge  and  forceps. 

Dorso-radial  Incision  (Von  Langenbeck).  Fig.  58,  D. 
The  hand  is  bent  toward  the  inner  side,  and  an  incision 
is  begun  at  the  ulnar  border  of  the  second  metacarpal  bone 
near  its  middle  and  carried  upward  four  inches,  crossing 
the  ulnar  edge  of  the  tendon  of  the  extensor  carpi  radialis 
brevior,  where  it  is  inserted  into  the  base  of  the  third  meta- 
carpal bone,  and  splitting  the  dorsal  ligament  of  the  wrist 
exactly  between  the  tendons  of  the  extensor  secundi  iuter- 
nodii  and  extensor  of  the  forefinger.  This  incision  should 
be  carried  down  to  the  bone,  and  the  soft  parts  detached  on 
the  radial  side  with  an  elevator  ;  the  tendons,  where  they 
lie  in  the  grooves,  are  raised  bodily  with  the  periosteum, 
and  their  sheaths  are  not  opened. 

The  hand  is  flexed  so  as  to  make  the  first  row  of  carpal 
bones  present  in  the  wound  ;  the  scaphoid  is  separated  from 
the  trapezium  and  taken  out,  and  followed  in  turn  by  the 
semilunar  and  cuneiform,  the  interosseous  ligament  being 
cut  and  the  bones  pried  out  with  a  small  elevator.  The 
trapezium  and  pisiform  are  left  if  possible. 

To  take  out  the  second  row,  the  operator  steadies  the 
round  articular  end  of  the  os  magnum  with  the  fingers  of 
his  left  hand,  and,  while  an  assistant  abducts  the  thumb,  he 
divides  with  a  knife  the  connection  between  the  trapezium 
and  trapezoid,  passes  the  knife  into  the  carpo- metacarpal 
joint,  and  cuts  the  ligaments  on  the  dorsal  side  of  the  ends 


146  OPERATIVE  SURGERY. 

of  the  metacarpal  bones  while  an  aid  flexes  them.  In  this 
way  the  trapezoid,  magnum,  and  unciform  can  be  brought 
out  together. 

The  lateral  ligaments  are  then  carefully  separated  from 
the  radius  and  ulna,  the  bones  protruded  and  sawn  through. 

EXCISION   OF   THE    HIP-JOINT. 

In  this  joiut,  as  in  the  shoulder,  the  disease  is  often  con- 
fined to  the  head  of  the  bone,  and  under  such  circumstances 
partial  excision  should  be  performed.  When  the  acetabulum 
is  diseased  the  loose  pieces  must  be  picked  out  and  the 
gouge  applied  to  the  roughened  surface.  The  line  of  sec- 
tion of  the  femur  should  pass  below  the  great  trochanter, 
however  limited  the  disease  may  be,  for  if  this  process  is 
left  it  is  liable  to  protrude  through  the  wound  and  obstruct 
the  escape  of  the  secretions.  If  the  disease  extends  be- 
yond this  point,  additional  slices  must  be  removed,  or  the 
gouge  used  until  healthy  bone  is  reached. 

The  anatomical  disposition  of  the  parts  is  such  that  the 
joint  is  best  approached  from  the  outer  and  posterior  aspect, 
the  incision  passing  over  the  top  of  the  great  trochanter. 
Different  surgeons  have  inclined  the  upper  part  of  the  in- 
cision forward  and  backward  at  various  angles,  or  have 
dissected  up  a  triangular  flap,  its  apex  directed  sometimes 
upward,  sometimes  downward. 

Sayre's  Method.  (Fig.  59,  A.)  Enter  the  point  of  the 
knife  midway  between  the  anterior  superior  spine  of  the 
ilium  and  the  top  of  the  great  trochanter,  and  drive  it  down 
to  the  bone;  then,  keeping  it  firmly  in  contact  with  the 
bone,  draw  it  in  a  curved  line  to  the  top  of  the  trochanter, 
midway  between  its  centre  and  posterior  border,  thence  for- 
ward and  inward,  making  the  whole  length  of  the  incision 
from  four  to  eight  inches,  according  to  the  size  of  the  thigh. 
Make  sure  that  the  periosteum  is  divided  throughout. 

Then,  drawing  aside  the  soft  parts,  divide  the  periosteum 
transversely  just  opposite  to,  or  a  little  above,  the  lesser 
trochanter,  carrying  the  division  as  far  as  possible  around 
the  bone.  Beginning  at  the  angle  formed  by  the  two  in- 
cisions, raise  flic  periosteum  on  each  side,  together  with  its 


EXCISION  OF  JOINTS  AND  BONES. 


147 


membranous  attachment,  as  far  as  the  digital  fossa.  Then, 
substituting  a  knife  for  the  periosteal  elevator,  divide  the 
insertions  of  the  muscles  at  this  point,  keeping  close  to  the 
bone,  and  afterward  separate  the  remaining  periosteum  as 
far  as  can  be  done  without  tearing  it.  Then  adduct  the  leg 
slightly  and  raise  the  head  of  the  femur  gently  out  of  the 
acetabulum  ;  this  will  detach  the  last  of  the  periosteum,  and 
allow  the  finger  to  be  passed  around  the  bone  as  a  guide  for 
the  saw,  which  should  be  applied  just  above  the  lesser  tro- 
chanter. 

If  the  bone  cannot  be  readily  dislocated,  saw  it  through 
first,  and  then  remove  the  head  with  the  forceps  or  elevator. 

Fig.  59. 


Excision  of  the  hip.    A.  Sayre.    B.  Oilier. 

If  the  acetabulum  is  perforated,  the  edges  must  be  chipped 
off  very  carefully  down  to  the  point  at  which  the  periosteum 
on  the  pelvic  side  is  still  adherent. 

Ollier's  Method.  (Fig.  59,  B.)  Oilier  makes  a  some- 
what similar  incision.     It  begins  four  fino-cr-breadths  below 


148  OPERATIVE  SURGERY. 

the  crest  of  the  ilium,  and  the  same  distance  behind  the 
anterior  superior  spine,  runs  downward  to  the  most  promi- 
nent part  of  the  great  trochanter,  and  thence  directly  down 
the  shaft  of  the  femur.  Its  upper  part  should  involve  the 
skin  and  fascia  only.  The  posterior  lip,  including  the 
glutseus  maximus,  is  drawn  back,  exposing  the  glutseus 
medius,  the  fibres  of  which  are  then  separated  without  cut- 
ting them.  This  permits  the  attachments  of  the  glutseus 
medius  to  be  preserved,  and  the  glutseus  minimus  can  be 
exposed  by  drawing  apart  the  edges  of  the  opening  made 
in  the  other,  and  then  divided  in  the  same  manner  or  drawn 
forward  with  a  blunt  hook. 

The  capsule  is  split  from  the  edge  of  the  cotyloid  cavity 
to  the  digital  fossa,  and  detached  together  with  the  ten- 
dinous insertions.  The  head  of  the  femur  is  dislocated 
backward,  the  ligamentum  teres  divided,  and  the  deuuda- 
tion  continued  downward  to  the  lesser  trochanter.  The 
bone  is  then  protruded  and  sawn  off  with  a  chain  or  com- 
mon saw. 

LangenbecJc's  Method.  The  thigh  is  flexed  at  an  angle 
of  45°  and  rotated  inward.  The  knife  is  entered  just 
below  a  point  opposite  the  junction  of  the  upper  and  mid- 
dle thirds  of  a  line  joining  the  posterior  superior  spine  of 
the  ilium  and  great  trochanter ;  in  other  words,  just  below 
the  most  anterior  portion  of  the  great  sciatic  notch.  Thence 
following  the  long  axis  of  the  flexed  femur  it  is  carried  in 
a  straight  line  over  the  outer  surface  of  the  great  trochanter, 
making  an  incision  which  penetrates  to  the  bone  through- 
out aud  is  about  four  or  five  inches  long.  The  glutei  are 
thus  divided  in  the  direction  of  their  fibres,  the  margins  of 
the  wound  retracted,  and  the  capsule  opened  by  a  longi- 
tudinal aided  by  a  transverse  incision  close  to  the  edge  of 
the  acetabulum.  After  severing  the  attachments  of  the  mus- 
cles to  the  great  trochanter  the  head  of  the  bone  is  dislo- 
cated backward  and  brought  out  of  the  wound  aud  sawed  off. 

Anterior  Incision.  Roser  recommends,  in  order  to  pre- 
serve the  trochanter,  an  anterior  incision  in  the  line  of  the 
neck  of  the  femur,  beginning  just  outside  the  crural  nerve, 
and  dividing  the  iliacus,  rectus,  sartorius,  and  tensor  vaginre 


EXCISION  OF  JOINTS  AND  BONES.  149 

femoris.  The  capsule  is  divided  in  the  same  line,  the  head 
turned  forward  into  the  wound  by  rotating  the  thigh  out- 
ward, and  sawn  off. 

Liicke  and  Schede  have  modified  this  by  making  the  in- 
cision vertical  instead  of  transverse,  beginning  outside  the 
crural  nerve  a  little  below  and  to  the  inner  side  of  the  ante- 
rior superior  spine  of  the  ilium,  and  running  directly  down- 
ward. The  inner  borders  of  the  sartorius  and  rectus  are 
exposed  and  drawn  outward,  and  then  the  outer  border  of 
the  psoas-iliacus  exposed  and  drawn  inward.  Then  the 
thigh  is  flexed,  abducted,  and  rotated  outward,  and  the 
capsule  divided. 

A  similar  incision  and  approach  to  the  joint  may  be 
used  in  the  operative  reduction  of  old  dorsal  dislocation. 

Barker1  employs  the  following  method  :  The  incision 
begins  on  the  front  of  the  thigh  half  an  inch  below  the 
anterior  superior  spine  of  the  ilium,  and  extends  about 
three  inches  downward  and  a  little  inward.  The  muscles 
are  recognized  as  the  successive  layers  of  tissue  are  divided. 
The  tensor  vagina?  femoris  and  glutei  are  drawn  to  the 
outer  side,  the  sartorius  and  rectus  to  the  inner,  and  the 
neck  of  the  femur  exposed.  The  external  cutaneous  nerve 
will  be  encountered  in  the  upper  angle  of  the  incision  ; 
lower  down  and  deeper  are  the  external  circumflex  vessels. 
The  deeper  part  of  the  incision  need  not  be  made  as  long 
as  the  more  superficial.  Any  abscess  which  may  be  opened 
should  be  thoroughly  washed  out  before  proceeding  fur- 
ther. 

The  neck  of  the  femur  is  divided  with  a  narrow  saw  in 
the  direction  of  the  external  wound,  and  the  diseased  head 
removed  with  sequestrum-forceps.  The  acetabulum  and  all 
other  parts  of  the  joint-cavity  are  explored  by  the  forefinger, 
and  any  diseased  tissue  cut  or  scraped  away.  Mr.  Barker 
fills  the  wound  with  iodoform  emulsion  and  generally 
closes  it  up  tight.  The  patient  is  placed  upon  a  double 
Thomas  splint  for  several  weeks. 

Arthreetomy  of  the  Hip-joint  by  Chiselling  through  the 
Great    Trochanter  (Tiling).      An   incision   three   or   four 

i  Brit.  Med.  Journ.,  19,  18S9. 


150 


OPERATIVE  SURGERY 


inches  long  is  made  along  the  anterior  border  of  the  great 
trochanter,  which  is  chiseled  off  and  laid  back.  The  cap- 
sule of  the  joint  is  divided  longitudinally,  the  periosteum 
elevated  from  the  neck  of  the  femur,  and  the  head  of  the 
femur  dislocated.  Then  the  lesser  trochanter  is  also  chiseled 
off  aud  the  acetabulum  cavity  is  freely  accessible. 


ANCHYLOSIS   OF   THE    HIP- JOINT.1 

When  the  anchylosis  is  not  associated  with  the  loss  of  a 
great  part  of  the  head  and  neck  of  the  femur — that  is,  when 
it  follows  inflammation  of  the  joint  due  to  rheumatism, 
pyaemia,  traumatism,  or  chronic  disease  that  has  been  ar- 
rested at  an  early  stage — Mr.  Adams's  operation  of  sub- 
cutaneous division  of  the  neck  of  the  femur  may  be  appli- 
cable, but  usually  division  below  one  or  both  of  the  trochan- 
ters, or  excision  of  the  head  aud  neck,  is  to  be  preferred. 

Pig.  60. 


Subcutaneous  division  of  the  neck  of  the  femur. 

Division  below  the  lesser  trochanter  is  only  undertaken 
to  remedy  a  faulty  position  of  the  limb,  for  there  can  be  no 
question  of  establishing  a  new  joint  below  the  insertion  of 

1  This  subject,  which  properly  belongs  under  osteotomy,  Is  placed  here  on  ac- 
count of  Its  Intimate  relations  with  excision  of  the  joint. 


EXCISION  OF  JOINTS  AND  BONES.  151 

the  psoas  and  iliacus.  It  is  doubtful  also  if  a  permanently 
movable  joint  can  be  obtained  by  division  at  a  higher  point ; 
it  certainly  cannot  unless  a  portion  of  the  bone  is  removed, 
and  probably  not  even  then,  for  the  tendency  of  the  cut 
ends  to  unite  after  a  time  is  very  great. 

Subcutaneous  Division  of  the  Neck  of  the  Femur  (Adams1). 
The  only  special  instrument  needed  is  a  saw  somewhat 
resembling  a  tenotomy  knife,  the  cutting  part  being  one 
and  a  half  inches  long  and  three-eighths  of  an  inch  wide, 
and  the  shank  about  two  and  a  half  inches  long.  (Fig.  61.) 

A  tenotomy  knife  is  entered  a  little  above  the  top  of  the 
great  trochanter  and  pushed  straight  into  the  neck  of  the 
femur,  dividing  the  muscles  and  opening  the  capsule  freely. 
The  soft  parts  being  fixed  by  the  thumb  and  fingers  of 
the  left  hand,  the  knife  is  withdrawn  and  the  saw  passed 
promptly  down  to  the  bone  through  the  track  made  by  it. 


Fig.  61. 
Adams's  saw  for  subcutaneous  division  of  the  neck  of  the  femur. 

The  bone  is  then  sawn  through  from  before  backward,  so 
that  the  line  of  section  shall  be  at  right  angles  to  the  long 
axis  of  the  neck,  care  being  taken  to  avoid  cutting  obliquely 
through  the  neck,  or  in  a  direction  parallel  with  the  shaft  of 
the  bone. 

Subtrochanteric  Osteotomy  (Gant's  Operation1).  An  inci- 
sion is  made  from  one  to  two  inches  long  on  the  outer 
aspect  of  the  thigh  an  inch  to  an  inch  and  a  half  below  the 
great  trochanter,  according  to  the  size  of  the  patient.  It 
should  expose  the  external  surface  of  the  femur  just  below 
the  site  of  the  lesser  trochanter.  The  blade  of  the  osteotome 
is  introduced  through  this  incision,  and  the  bone  divided 
just  below  the  trochanter  minor.  After  each  stroke  of  the 
mallet  the  chisel  is  loosened  and  its  direction  slightly  changed 

1  An  operation  for  bony  anchylosis  of  the  hip-joint  with  malposition  of  the 
limb,  by  subcutaneous  division  ot  the  neck  of  the  thigh  bone,  by  William  Adams. 
London,  1871.    Reprinted  from  the  British  Medical  Journal  of  December  24,1870, 

2  Gant's  "  Science  and  Practice  of  Surgery,"  1886. 


152  OPERATIVE  SURGERY. 

to  cut  forward  or  backward.  The  bone  should  not  be  cut 
entirely  through,  but  when  it  seems  evident  that  only  a  thin 
shell  is  left  it  should  be  carefully  fractured.  The  after- 
treatment  consists  in  simple  extension. 

The  operations  of  Adams  and  Grant  are  the  ones  most  gen- 
erally employed  for  the  correction  of  deformity  following 
anchylosis  at  the  hip  in  a  faulty  position.  Adams's  method 
is,  of  course,  only  applicable  to  those  cases  in  which  the 
femur  still  possesses  a  neck,  and  inasmuch  as  the  disease 
which  most  frequently  calls  for  this  kind  of  interference — 
namely  tuberculosis — generally  causes  more  or  less  destruc- 
tion of  the  head  and  neck  of  the  femur,  the  operation  of 
Gant,  or  subtrochanteric  osteotomy,  has  a  wider  use. 

Excision.  Posterior  incision  as  above  described,  with 
such  modifications  as  may  be  made  necessary  by  disloca- 
tion ;  division  of  the  neck  with  the  saw,  if  possible  ;  other- 
wise with  the  chisel ;  then  removal  of  the  head,  or  what 
remains  of  it,  by  chiselling. 

The  upper  end  of  the  bone  is  then  lodged  in  the  acetabu- 
lum, after  subcutaneous  division  of  such  muscles  and  soft 
parts  as  interfere,  and  removal  of  the  upper  part  of  the 
trochanter,  if  necessary.  Extension  by  weight  and  pulley 
must  be  kept  up  for  a  long  time. 


EXCISION    OF   THE    KNEE-JOINT. 

This  should  always  be  complete  to  this  extent,  that  a 
slice  should  be  taken  from  each  bone;  but  it  is  not  always 
necessary  to  remove  the  entire  articular  surface  of  the  femur. 
In  children  the  amount  removed  should  be  as  small  as  is 
consistent  with  removal  of  all  that  is  diseased.  The  patella 
may  be  dissected  out  and  removed  entire,  or  the  diseased 
portions  extirpated  with  the  gouge  or  rongeur  ;  or  it  may 
be  sawn  through  parallel  with  its  articular  surface.  As  a 
general  tiling  the  latter  method  is  preferable,  unless  the 
bone  is  so  extensively  affected  that  the  preservation  of  even 
its  anterior  surface  is  incompatible  with  a  thorough  removal 
of  all  the  disease. 

As  anchylosis  should  always  be  aimed  at,  the  incision 


EXCISION  OF  JOINTS  AND  BONES. 


153 


may  cross  the  front  of  the  joint  and  divide  the  ligamentum 

patellae  or  the  patella.     Some  surgeons  provide  for  drainage 

by  making  a  dependent  opening  in 

the  popliteal  space,  but  this  seems  fig.  62. 

to  be  unnecessary. 

Semilunar  Incision.  (Fig.  62, 
A.)  The  knife  is  entered  on  one 
side  of  the  limb  at  the  posterior 
part  of  the  condyle,  and  carried 
across  midway  between  the  patella 
and  the  tuberosity  of  the  tibia  to 
a  corresponding  point  upon  the 
other  side.  This  incision  should 
extend  down  to  the  bone  through- 
out, dividing  the  ligamentum  pa- 
tella?. The  flap  is  reflected,  the 
crucial  ligaments  divided  close  to 
their  attachment  to  the  tibia,  the 
lateral  ligaments  divided,  the  end 
of  the  femur  cleared  as  far  as  may 
be  necessary,  with  especial  care  for 
the  safety  of  the  popliteal  vessels, 

protruded  through  the  wound,  and  sawn  off  at  the  point 
indicated  in  Figs.  63  and  64.  The  line  of  section  must  be 
parallel  to  the  line  of  the  articulation,  not  at  a  right-angle 
to  the  axis  of  the  shaft,  for  that  is  directed  inward  and 
downward.  If  necessary,  additional  slices  of  the  bone  are 
removed,  or  the  gouge  is  used.  All  the  articular  cartilages 
should  be  removed. 

The  end  of  the  tibia  is  next  projected,  cleaned,  and  sawn 
off  about  half  an  inch  below  its  upper  surface. 

In  sawing  the  bones  it  is  best  not  to  make  a  complete 
section  with  the  saw,  but  to  stop  a  little  short  of  the  poste- 
rior surface  and  complete  the  separation  by  fracturing  what 
is  left. 

Finally,  the  patella  is  taken  out,  and  diseased  portions 
of  the  synovial  membrane  scraped  or  clipped  off,  or  the 
articular  surface  of  the  patella  may  be  removed  with  the 
saw  or  rongeur,  and  the  anterior  bony  shell  which  is  at- 
tached to  the  quadriceps  tendon  left.     The  operation  is 


Excision  of  the  knee-joint. 

A.  Semilunar  incision. 

B.  Ollier's  incision. 


154 


OPERATIVE  SURGERY. 


completed  by  suturing  in  position  the  divided  ligamentum 
patellae. 


Fig.  63. 


Fig.  64. 


Sections  to  show  the  position  of  the  epiphyseal  cartilage  at  the  knee  and  the 
points  at  which  the  section  ought  to  be  made  in  excision. 

Transverse  Incision.     The  incision  should  cross  the  pa- 
tella at  or  just  below  its  centre  and  extend  beyond  the  centre 


EXCISION  OF  JOINTS  AND  BONES.  155 

of  the  condyle  on  each  side ;  at  each  end  should  be  made  a 
longitudinal  incision  extending  two  inches  above  and  one 
inch  below  the  transverse  one ;  the  patella  is  then  divided 
at  its  centre  transversely,  and  the  fragments  turned  up  and 
down,  and  the  joint  thus  opened  and  cleaned. 

At  the  close  of  the  operation  the  patella  is  replaced  and 
united  with  sutures ;  the  patella  may  be  entirely  removed  ; 
or,  in  the  first  place,  after  exposing  the  boue,  the  patella 
may  be  dissected  out,  and  at  the  close  of  the  operation  the 
quadriceps  tendon  reunited. 

Arthrectomy,  or  Extirpation  of  the  Knee-joint.  This  term 
has  been  given  to  the  systematic  removal  of  the  synovial 
membrane  and  any  small  portions  of  the  rest  of  the  artic- 
ulation which  may  on  inspection  be  found  to  be  diseased. 
The  above-described  semilunar  incision  is  employed,  and 
the  anterior  flap  containing  the  patella  reflected.  After 
removing  all  pulpy  and  degenerated  tissue  in  the  subcrural 
pouch  the  lateral  and  crucial  ligaments,  if  necessary,  are 
cut,  although  the  latter  should  be  spared  whenever  possible. 
The  joint  is  thus  thoroughly  exposed,  and  all  the  diseased 
parts  in  its  interior  excised,  together  with  the  semilunar 
cartilages.  Foci  of  inflammation  in  the  bone  must  be 
removed  with  the  sharp  spoon  or  rongeur.  The  field  of 
operation  is  then  flushed  out  with  some  antiseptic  solution, 
the  ligamentum  patelhe  sutured  in  position,  and  the  cuta- 
neous wound  loosely  united.  Whenever  it  is  deemed  desir- 
able drainage-tubes  may  be  inserted  in  the  posterior  angles 
of  the  incision.  Immobilization  of  the  leg  in  extension 
must  be  maintained  for  several  weeks. 


EXCISION    OF   THE   ANKLE-JOINT. 

The  results  of  excision  of  the  ankle-joint  have  been,  on 
the  whole,  so  unfavorable  that  the  English  and  German 
surgeons  are  inclined  to  abandon  it  entirely.  When  the 
operation  has  been  undertaken  on  account  of  caries,  the 
disease  has  usually  returned  in  the  tarsal  bones,  and  ren- 
dered secondary  amputation  necessary.  When,  on  the  other 
hand,  it  has  been  performed  on  account  of  injury,  the  mor- 
tality has  been  great,  secondary  amputation  has  been  fre- 


156 


OPERATIVE  SURGERY. 


Fig.  65. 


quently  required,  and  the  position  of  the  foot  in  the  cases 
that  recovered  has  usually  been  faulty. 

The  results  of  conservative  expectant  treatment  have 
been  no  better,  and,  in  part,  for  the  same  reasons.  In 
correspondence,  as  has  been  pointed  out,  with  the  late  con- 
solidation of  the  epiphysis,  inflammation  of  this  extremity 
is  likely  to  be  severe,  and  its  destructive  results  extensive ; 
the  reproduction  of  bone  is  also  very  abundant  and  leads 
almost  necessarily  to  anchylosis,  so  that,  unless  great  atten- 
tion is  given  to  maintaining  the  foot  in  a  proper  position 
during  the  whole  period  of  treatment,  it  will  unite  at  a 
faulty  angle,  with  inversion  or  eversion  of  the  sole,  and 
inability  to  support  the  weight  of  the  body. 

As  anchylosis  is  to  be  expected,  the  rule  in  excision  is  to 
remove  the  smallest  possible  amount  of  bone,  and  to  make 
partial  instead  of  complete  excision 
when  the  disease  does  not  extend 
to  the  whole  joint.  The  retention 
of  one  or  the  other  malleolus  is  a 
great  help  in  preventing  shortening, 
and  in  the  use  of  a  plaster  splint. 
The  interosseus  membrane  between 
the  tibia  and  fibula  must  be  pre- 
served carefully.  It  not  only  has 
a  great  tendency  to  ossify,  but  also 
seems  to  favor  the  reproduction  of 
bone. 

Operation  (total  excision).  An 
incision  involving  only  the  skin  is 
begun  two  inches  above  the  external 
malleolus  and  a  little  behind  the 
middle  of  the  fibula,  carried  directly 
dowD  to  the  end  of  the  bone,  and 
thence  forward  and  slightly  upward 
toward  the  instep  for  an  inch  (Fig. 
65).  The  periosteum  covering  the 
fibula  is  divided  throughout  and 
dissected  up  from  the  bone  with  the  attachment  of  the  lateral 
ligaments,  especial  care  being  taken  not  to  open  the  sheath 
of  the  peroneal  muscles  at  the  posterior  border  of  the  malle- 
olus, and  to  remove  all  the  thick  periosteum  and  the  interos- 


Excision  of  ankle. 


EXCISION  OF  JOINTS  AND  BONES.  157 

seous  membrane  on  the  inner  side.  If  necessary,  a  trans- 
verse liberating  incision  may  be  made  through  the  perios- 
teum at  the  upper  end  of  the  cut.  The  bone  is  then  divided 
with  a  keyhole  saw  or  chisel,  the  upper  end  of  the  lower 
fragment  drawn  out  of  the  wound  to  expose  and  facilitate 
the  separation  of  the  remaining  attachments,  and  the  piece 
removed. 

The  soft  parts  are  then  held  out  of  the  way  with  retrac- 
tors, and  the  upper  articular  surface  of  the  astragalus  sawn 
off  with  the  keyhole  saw,  but  not  removed. 

The  foot  is  next  turned  upon  its  outer  side,  and  a  longi- 
tudinal incision  two  or  three  inches  long  made  along  the 
side  of  the  tibia,  ending  half  an  inch  below  the  tip  of  the 
malleolus,  where  it  is  then  crossed  by  a  short  horizontal 
one  involving  the  skin  only.  The  periosteum  of  the  tibia 
is  divided  in  the  line  of  the  incision  and  transversely  at  its 
upper  end,  and  dissected  off,  the  bone  sawn  through,  and 
the  piece  removed.  Langenbeck  makes  the  line  of  section 
oblique  downward  and  outward,  because  it  is  easier  to  do 
so,  but  most  surgeons  prefer  to  have  it  transverse.  The 
upper  part  of  the  astragalus,  which  has  been  previously 
sawn  off,  is  then  removed  through  the  same  incision. 

The  gouge  is  used  to  scrape  away  any  diseased  parts 
found  on  the  cut  surface  of  the  astragalus,  or  the  bone  may 
be  seized  with  strong  forceps  and  dissected  out  entirely. 

If  the  injury  has  affected  the  astragalus  only  (as  in  some 
gunshot  wounds),  its  splinters  are  best  removed  through  a 
longitudinal  incision  upon  the  dorsum  of  the  foot  between 
the  extensor  tendons  of  the  first  and  second  toes. 

Vogfs  Method,  by  Removal  of  the  Astragalus.  A  serious 
objection  to  the  use  of  the  preceding  operation  in  cases  of 
tuberculous  disease  lies  in  its  insufficient  exposure  of  the 
interior  of  the  joint  to  view,  and  it  has  been  proposed  by 
Hueter  to  return  to  the  old  method  of  an  anterior  trans- 
verse incision  with  division  of  all  the  extensor  tendons,  and 
by  Busch  to  open  the  joint  by  cutting  across  the  sole  and 
sawing  through  the  calcaneum.     Vogt,1  however,  has  pro- 

1  Centralblatt  fur  Chirurgie,  18S3,  p.  289. 


158  OPERATIVE  SURGERY. 

posed  and  employed  another  method,  which  avoids  the 
extensive  division  of  the  soft  part  and  which  enables  the 
surgeon  to  explore  the  joints  thoroughly,  and,  if  necessary, 
to  excise  the  synovial  membrane.  It  consists  in  primary 
methodical  extirpation  of  the  astragalus  without  resection 
of  the  malleolus. 

Operation.  A  longitudinal  incision  on  the  outer  side  of 
the  extensor  tendons,  three  or  four  inches  long,  beginning 
above  between  the  tibia  and  fibula,  and  ending  below  at 
the  line  of  the  calcaneo-cuboid  joint ;  after  division  of  the 
fascia  the  tendons  are  raised  in  their  sheaths,  carefully 
separated  from  the  underlying  parts,  and  strongly  retracted 
to  the  inner  side.  The  extensor  brevis  is  then  cut,  the  outer 
side  of  the  incision  retracted,  the  capsule  split  longitudi- 
nally to  its  full  extent  and  separated  on  both  sides  from 
the  bone  with  knife  and  elevator,  the  head  and  neck  of 
the  astragalus  cleared,  and  the  astragalo-scaphoid  ligament 
divided. 

A  second  incision  is  made  from  a  point  somewhat  below 
the  centre  of  the  first  backward  below  the  external  mal- 
leolus, dividing  everything  down  to  the  astragalus,  but 
sparing  the  peroneal  tendons.  The  foot  is  then  supinated, 
the  anterior  ligaments  cut  away  from  the  external  mal- 
leolus, and  the  strong  interosseous  ligament  divided  by 
thrusting  a  small  strong  knife  into  the  groove  between  the 
astragalus  and  calcaneum.  The  head  of  the  astragalus  is 
then  drawn  forcibly  outward  with  a  stout  hook,  while  the 
foot  is  supinated,  the  deep  portion  of  the  internal  lateral 
ligament  cut  by  passing  a  knife  between  the  malleolus  and 
the  astragalus,  the  latter  drawn  forward  into  the  incision, 
and  its  posterior  attachments  cut. 

The  remainder  of  the  operation  will  vary  with  the  extent 
and  character  of  the  disease.  All  the  adjoining  bones  are 
freely  exposed  to  inspection,  and  can  be  scraped,  gouged 
out,  or  sawn  off. 

I  have  found  the  execution  of  this  operation  easy,  even 
when  the  capsule  was  much  thickened  by  disease,  and  its 
exposure  of  the  interior  of  the  joint  is  very  satisfactory. 


EXCISION  OF  JOINTS  AND  BONES. 


159 


osteoplastic  excision  of  the  foot  (heel  and 
ankle)  (Mikulicz). 

This  ingenious  operation,  the  results  of  which  have 
proved  very  satisfactory,  was  introduced  by  Mikulicz  in 
1881.1  It  is  specially  applicable  to  cases  in  which  the  in- 
tegument about  the  heel  has  been  extensively  destroyed. 

Fig.  66. 


Osteoplastic  excision  of  the  foot.    (Mikulicz.) 


Operation.     (Fig.  66.)     Abdominal  decubitus.     An  in- 
cision beginning  a  little  in  front  of  the  tubercle  of  the 

1  Archiv  fur  klinische  Chirurgie,  vol.  xxvi.,  p.  191. 


160 


OPERATIVE  SURGERY. 


scaphoid  is  carried  directly  across  the  sole  of  the  foot  to 
a  point  just  behind  the  base  of  the  fifth  metatarsal  bone. 
From  each  end  of  this  one  another  incision  is  carried  back- 
ward and  upward  to  the  base  of  the  corresponding  mal- 
leolus, and  the  upper  ends  of  the  last  two  incisions  are  then 
united  by  a  fourth  which  passes  horizontally  across  and 
divides  the  tendo  Achillis.  In  all  the  incisions  the  knife  is 
made  to  touch  the  bone  throughout. 

The  lateral  ligaments  of  the  ankle  are  next  divided,  the 
joint  opened  from  behind,  and  the  calcaneum  and  astra- 
galus carefully  dissected  from  the  tissues  in  front  of  the 
incisions  and  removed  by  disarticulating  at  the  medio- 
tarsal  joint. 

Finally,  the  malleoli  and  lower  articular  surface  of  the 
tibia  and  the  posterior  portion  of  the  cuboid  and  scaphoid 
are  sawn  oif,  as  shown  by  the  dotted  lines  in  the  figure,  the 
cut  being  made  from  behind  forward. 

Fig.  67. 


External  incision  for  the  operative  treatment  of  old  unreduced  Pott's  fracture. 
The  astragalus  is  displaced  backward.  Its  articular  surface  is  partially  occupied 
by  the  new  osteoid  tissue  developed  under  the  periosteal  bridge  at  the  lower  end 
of  the  posterior  surface  of  the  tibia. 


The  cut  surfaces  of  bone  are  then  brought  into  apposi- 
tion and  fastened  together  with  nails  or  sutures,  and  the 
wound  closed.     Fig.  66,  B,  represents  the  result. 


EXCISION  OF  JOINTS  AND  BONES. 


161 


Operative  Treatment  of  Old  Unreducible  Pott's  Fracture.1 
The  Esraarch  rubber  bandage  or  tourniquet  is  applied  and 
tied  below  the  knee.  An  incision  is  begun  on  the  outer 
side  three  inches  above  the  ankle,  and  carried  down  along 
the  front  of  the  fibula  to  the  malleolus,  and  thence  in  a 
curve  forward  toward  the  fifth  metatarsal  (Fig.  67).  The 
seat  of  the  fibular  fracture  is  exposed,  and  the  lower  frag- 
ment again  separated  with  the  chisel. 

A  second  longitudinal  incision  about  five  inches  long  is 
made  over  the  inner  side,  extending  past  the  malleolus  to 
the  tubercle  of  the  scaphoid  (Fig.  68).     Through  it  the 


Fig.  68. 


Internal  incision  for  the  operative  treatment  of  old  unreduced  Pott's  fracture. 
The  astragalus  is  represented  as  displaced  backward. 

mass  of  new  tissue  that  has  formed  between  the  astragalus 
and  the  internal  malleolus  is  removed  or  the  broken  and 
displaced  malleolus  is  mobilized. 

By  now  working  through  both  incisions  the  back  of  the 
lower  end  of  the  tibia  can  be  freed  of  such  cicatricial  tissue 
or  new  bone  as  has  formed  there,  and  the  foot  so  mobilized 
that  it  can  be  brought  back  to  its  proper  place.  The  perios- 
teum and  ligaments  are  sutured  in  position  with  catgut,  the 
wound  loosely  closed  without  drainage,  and  after  applying 
a  bulky  dressing  the  tourniquet  is  removed. 


1  Stimson :  N.  Y.  Medical  Journal,  June  25, 1892. 


1 62  OPERATIVE  SUBGEB Y. 


EXCISION  OF  THE  BONES  AND  SMALLER 
ARTICULATIONS. 

EXCISION    OF   THE   SUPERIOR   MAXILLA. 

This  operation  may  be  required  on  account  of  malignant 
tumors  of  the  bone  or  antrum,  or  of  suppurative  osteitis 
and  necrosis,  or  to  give  access  to  the  base  of  implantation 
of  a  naso-pharyngeal  polyp.  In  the  first  case  the  perios- 
teum should  not  be  retained ;  in  the  second  its  separation 
from  the  boue  is  in  great  part  accomplished  by  the  inflam- 
matory process;  in  the  third  it  should  be  carefully  retained 
so  as  to  diminish  the  subsequent  deformity. 

In  total  excision  the  bony  connections  that  require  to  be 
divided  are :  (1)  The  one  with  the  malar  bone  below  the 
outer  angle  of  the  orbit.  (2)  That  with  the  opposite  bone 
along  the  centre  of  the  hard  palate.  (3)  Those  formed  by 
the  nasal  process  near  the  inner  angle  of  the  orbit;  and  (4) 
that  with  the  palate  bone  and  pterygoid  process  of  the 
sphenoid.  (Fig.  69.)  The  first  may  be  divided  by  nicking 
the  anterior  surface  of  the  bone  with  a  saw,  and  completing 
the  division  with  cutting  forceps,  or  with  chisel  and  mallet, 
or  by  passing  a  chain-saw  around  it,  through  the  spheno- 
maxillary fissure  in  the  orbit  and  zygomatic  fossa.  The 
second  is  divided,  after  having  drawn  one  or  both  incisor 
teeth,  by  means  of  a  saw  passed  into  the  nostril,  or  with 
cutting  forceps  with  long  narrow  blades,  or  a  chisel.  The 
third  is  easily  divided  with  forceps  or  a  chisel,  and  the 
fourth  by  twisting  the  bone  downward  after  all  the  other 
connections  have  been  severed. 

The  periosteum,  covering  the  floor  of  the  orbit,  is  thick 
and  easily  detached ;  that  on  the  hard  palate  is  thick  and 
difficult  of  removal,  on  account  of  the  irregularities  of  the 
surface.  There  is  but  little  danger  of  injury  to  the  internal 
maxillary  artery,  and  it  is  seldom  necessary  to  apply  more 
than  one  or  two  ligatures  to  its  divided  branches.  Oozing 
is  arrested  by  parking  with  aseptic  or  iodoform  gauze. 

In  partial  excision  the  orbital  plate  is  left,  the  line  of 
division  of  the  bone  passing  through  the  anterior  wall  of 
the  antrum  from  the  nostril  to  the  lower  corner  of  the 


EXCISION  OF  JOINTS  AND  BONES. 


163 


union  with  the  malar  bone.  The  remaining  attachments 
are  then  broken  as  before.  There  are  also  other  varieties 
of  partial  excision  for  the  removal  of  naso-pharyngeal 
polypi ;  removal  of  the  nasal  process  with  the  nasal  bone ; 
removal  of  part  of  the  hard  palate  (Nelaton) ;  and  tempo- 
rary removal  of  different  portions,  preserving  the  connec- 
tion with  the  soft  parts,  and  replacing  them  after  the  polypi 
has  been  removed. 

Fig.  69. 


Lines  of  bony  division  in  the  different  operations  on  the  superior  and  inferior 

maxillae. 
A,  B,  C.  Total  excision  of  the  superior  maxilla.    X>.  Boeckel's  operation.    E,  C. 
Guerin's  operation.    F,  F.  Langenbeck's  operation  for  naso-pharyngeal  polypus. 
G.  Excision  of  inferior  maxilla.    H.  Removal  of  a  portion  of  the  alveolus  (e.  g., 
for  epulis).    I.  Esmarch's  operation  for  anchylosis  of  inferior  maxilla. 

The  incisions  that  have  been  proposed  may  be  classed  as 
(1)  external  and  (2)  median ;  the  former  extending  from 


164  OPERATIVE  SURGERY. 

the  augle  of  the  mouth  upward  and  outward  to  the  malar 
bone ;  the  latter  passing  from  or  near  the  middle  of  the  lip 
up  toward  the  inner  angle  of  the  eye.  The  former  are  open 
to  the  objections  that  they  divide  the  branches  of  the  facial 
nerve,  endauger  Steno's  duct,  and  leave  a  conspicuous  scar. 
The  preference  is  now  generally  accorded  to  the  median  in- 
cisions. These  follow  the  outline  of  the  side  of  the  nose 
more  or  less  closely,  and  some  of  them  are  supplemented 
by  a  transverse  incision,  passing  a  quarter  of  an  inch  below 
the  lower  margin  of  the  orbit.  For  partial  excision  Guerin 
recommends  an  incision  passiug  from  the  side  of  the  wing  of 
the  nose  aloug  the  naso-labial  fold  to  the  augle  of  the  mouth 
(Figs.  69,  70,  71). 

In  order  to  avoid  the  swallowing  of  blood,  it  is  well  not 
to  carry  the  incision  through  the  lip  or  divide  the  gingivo- 
labial  fold  until  after  the  anterior  face  of  the  bone  has  been 
denuded  as  far  as  possible. 

It  is  possible  to  remove  the  superior  maxilla  through  the 
mouth  without  making  any  cutaneous  incisions,  but  it  is  a 
very  difficult  and  painful  operation,  and  the  hemorrhage 
is  most  embarrassing.  Larghi  has  removed  both  bones 
through  the  mouth,  upon  the  cadaver,  and  says  it  is  easier 
to  remove  both  together  than  one  aloue  in  this  way. 

In  simultaneous  excision  of  both  superior  maxillse,  the 
same  incisions  may  be  made  on  both  sides  as  for  the  re- 
moval of  only  one,  or  Dieffenbach's  median  incision  may 
be  made  along  the  ridge  of  the  nose  and  the  middle  of  the 
upper  lip. 

Operation  by  a  Median  Incision.  (Fig.  70,  B).  The 
usual  method  of  operation  is  as  follows :  The  incision  is 
begun  half  an  inch  below  the  inner  canthus  of  the  eye.  It  is 
carried  down  the  line  of  the  junction  of  the  nose  with  the 
face  and  along  the  groove  which  limits  the  ala  nasi,  thence 
horizontally  to  the  septum,  and  so  down  to  the  free  border 
of  the  lip  in  the  median  line. 

This  incision  may  be  supplemented,  if  necessary,  by  one 
joining  it  at  the  inner  canthus  and  following  the  edge  of 
the  orbit  outward. 

The  cartilage  of  the  nose  is  separated  from  the  bone  and 
reflected  inward  with  the  small  internal  flap,  the  edge  of 


EXCISION  OF  JOINTS  AND  BONES.  165 

the  orbit  cleared,  and  the  external  flap  dissected  outward  as 
far  as  to  the  malar  bone  above  and  the  tuberosity  of  the 
maxilla  below,  if  possible,  the  infraorbital  nerve  being 
divided  at  its  point  of  emergence  from  the  foramen. 

Fig.  70. 


Excision  of  superior  maxilla.    A.  External  incision.    B.  Nelaton's  incision. 
C.  Boeckel's  incision. 

The  periosteum  of  the  floor  of  the  orbit  is  then  detached 
with  the  handle  of  the  knife,  as  far  as  the  spheno-maxillary 
fissure,  the  malar  process  or  bone  cut  through  with  the  saw 
or  forceps,  and  the  thin  plate  of  bone  forming  the  floor  of 
the  orbit  divided  with  the  knife  obliquely  inward  and  for- 
ward from  the  anterior  end  of  the  spheno-maxillary  fissure. 
The  superior  maxillary  nerve,  which  can  be  readily  distin- 
guished through  the  bone,  should  also  be  divided  as  far 
back  as  possible.     Finally,  the  nasal  process  is  divided. 

The  incision  is  then  carried  through  the  lip,  and  the  de- 
tachment of  the  external  soft  parts  completed. 

The  mucous  membrane  of  the  roof  of  the  mouth  is  divided 
transversely  on  a  line  with  the  last  molar  tooth,  and  longi- 
tudinally in  the  median  line.  An  incisor  tooth  is  then 
drawn,  and  the  hard  palate  divided  with  saw  or  forceps 
close  to  the  septum. 

If  the  mucous  membrane  of  the  roof  of  the  mouth  is  not 
diseased  it  may  be  retained.  Instead  of  the  incisions  through 
it  just  mentioned,  one  is  made  along  the  inner  border  of  the 
alveolar  process,  its  edge  raised,  and  the  membranes  de- 
tached inward  and  backward  to  the  median  line.  After  the 
removal  of  the  bone  it  unites  with  the  cheek,  closes  in  the 

8* 


166 


OPERATIVE  SURGERY. 


mouth  as  before,  and  may  become  strengthened  by  a  deposit 
of  bone. 

Finally,  the  bone  is  grasped  with  strong  forceps,  twisted 
downward  to  break  its  posterior  connections,  and  removed, 
generally  bringing  with  it  part  of  the  palate  bone,  the 
hamular  process  of  the  pterygoid,  and  some  attached  mus- 
cular fibres. 

Subperiosteal  Excision  (Oilier).  This  method  can  be 
employed  with  the  median  incision  above  mentioned,  but 
Oilier  prefers  an  external  one  (Fig.  71,  B). 

Fig.  71. 


A.  Guerin's  incision  for  partial  removal  of  superior  maxilla.  B.  Ollier's  in- 
cision for  subperiosteal  excision  of  superior  maxilla.  0.  Dieffenbach's  median 
incision  for  removal  of  tooth  bones.  L.  Langenbeck's  incision  for  nasopharyn- 
geal polypus.    K.  Boeckel's  incision  for  naso-pharyngeal  polypus. 


1.  Cutaneous  Incision.  An  incision  is  made  from  the 
middle  of  the  malar  bone  to  a  point  on  the  upper  lip  one- 
third  of  an  inch  from  the  angle  of  the  mouth.  If  necessary, 
a  second  incision  must  be  made  at  the  middle  of  the  lip  and 
carried  upward  around  the  nostril. 

2.  Incision  of  Mucous  Membrane.  The  incision  is  begun 
on  the  outer  surface  at  the  interval  between  the  second  in- 
cisor and  the  canine  tooth  (he  does  not  remove  the  inter- 
maxillary bone,  that  which  supports  the  incisor  teeth)  close 
to  the  edge  of  the  gum,  carried  back  around  the  last  molar, 


EXCISION  OF  JOINTS  AND  BONES.  167 

then  forward  on  the  inside  to  a  point  corresponding  to  tha* 
at  which  it  was  begun,  and  thence  obliquely  backward  to 
the  median  line.  A  short  incision  through  the  periosteum 
is  next  made  from  the  anterior  external  extremity  of  the 
former  upward  and  inward  to  a  point  a  quarter  of  an  inch 
external  to  the  anterior  nasal  spine. 

3.  Separation  of  the  Periosteum.  The  periosteum  of  the 
anterior  surface  is  then  detached  with  an  elvator,  care  being 
taken,  however,  to  divide  the  infraorbital  nerve  with  a  knife 
at  its  point  of  emergence,  and  the  denudation  is  carried 
along  the  floor  of  the  orbit.  Unless  it  is  necessary  to  re- 
move the  nasal  process  of  the  maxilla,  the  lachrymal  sac 
and  duct  can  be  left  uninjured  and  adherent  to  the  peri- 
osteum. 

The  periosteum  of  the  roof  of  the  mouth  is  then  separated 
from  without  inward  as  far  as  the  median  line. 

4.  Section  of  the  Bone.  The  nasal  and  malar  processes 
are  divided  with  forceps,  chisel,  or  chain-saw,  as  before  de- 
scribed, the  canine  tooth  drawn,  the  edge  of  the  chisel  in- 
serted in  the  gap  left  by  it,  and  pressed  gently  backward 
and  inward  to  the  median  line,  thence  directly  backward 
along  the  suture. 

The  bone  is  then  twisted  out,  the  palatal  sutured  to  the 
external  periosteum,  aud  the  wound  closed. 

Excision  of  the  Portion  of  the  Superior  Maxilla  Lying 
Below  the  Infraorbital  Foramen  ( Guerin's  Operation).  (Figs. 
69,  E  C,  71,  A.)  An  incision,  slightly  convex  externally, 
is  made  from  the  ala  of  the  nose  to  the  angle  of  the  month, 
following  the  crease  usually  present  in  the  features  at  this 
situation.  The  alveolar  mucous  membrane  is  divided  at  the 
point  of  reflection  on  to  the  cheek  from  the  level  of  the 
last  molar  tooth  to  the  middle  line  anteriorly.  The  soft 
parts  are  dissected  up  and  the  nostril  opened  in  front.  A 
narrow  saw  is  passed  through  the  nares  and  the  maxilla 
sawn  horizontally  outward.  The  saw  cut  passes  below 
the  infraorbital  canal  well  above  the  teeth  and  through 
the  malar  process  and  maxillary  tuberosity ;  or  the  bone 
may  be  chiselled  through  on  this  line.  The  soft  palate  is 
detached  from  the  hard  by  a  transverse  incisiou  at  the  last 
molar  tooth.     A  middle  incisor  tooth  is  next  removed  and 


168  OPERATIVE  SURGERY. 

the  hard  palate  divided  in  the  median  line  with  a  saw, 
chisel,  or  forceps  introduced  through  the  nostril.  The  de- 
tached piece  of  bone  is  loosened  with  a  periosteal  elevator 
and  wrenched  out. 

This  operation  may  be  performed  subperiosteally  (usually 
for  naso-pharyngeal  polypus),  either  by  the  above-described 
or  by  a  median  incision.  The  muco-periosteum  is  divided 
horizontally  along  the  free  margiu  of  the  inner  and  outer 
faces  of  the  alveolar  process  on  the  affected  side,  from  the 
anterior  nasal  spine  around  behind  the  last  molar  tooth,  and 
elevated  to  the  middle  line  of  the  hard  palate  and  to  its 
posterior  border,  aud  upward  to  near  the  infraorbital 
foramen  on  the  outer  surface  of  the  superior  maxilla.  The 
lower  half  of  the  latter  is  next  removed  as  indicated  above, 
and  at  the  close  of  the  operation  the  mucous  membrane  is 
united  as  far  as  possible  by  sutures,  thus  shutting  off  the 
nasal  from  the  oral  cavity. 

This  operation  affords  an  excellent  view  of  the  naso- 
pharynx. 

Removal  of  the  Superior  Maxilla  Above  the  Alveolar  Pro- 
cess (Berard's  Operation).  The  median  incision  is  used 
from  below  the  inner  canthus  of  the  eye,  following  the 
junction  of  the  nose  and  face  through  the  centre  of  the 
upper  lip  (Fig.  70,  B).  The  soft  parts  on  the  affected  side 
are  raised  as  for  total  extirpation  of  the  maxilla,  and  the 
periosteum  of  the  floor  of  the  orbit  is  detached  as  far  as 
the  sphenomaxillary  fissure.  The  malar  process  is  di  vided, 
and  then  the  orbital  plate  inward  and  forward  from  the 
anterior  end  of  the  spheno-maxillary  fissure.  The  superior 
maxillary  nerve  is  cut  as  far  back  as  possible,  and,  finally, 
the  nasal  process. 

A  horizontal  saw-cut  is  then  made  outward  from  the 
nose  above  the  alveolar  process.  Any  adherent  structures 
between  the  outer  extremity  of  this  cut  and  that  through 
the  malar  process  are  freed  with  the  knife  or  periosteal 
elevator,  and  the  piece  of  bone  thus  mapped  out  is  pried 
or  wrenched  away.  The  sound  alveolar  process  is  left 
in  situ. 


EXCISION  OF  JOINTS  AND  BONES.  169 


SIMULTANEOUS   EXCISION   OF  BOTH  SUPERIOR  MAXILLAE. 

An  incision  may  be  made  from  each  angle  of  the  mouth 
to  the  malar  bone  and  the  broad  flap  reflected  toward  the 
forehead,  or  Dieffenbach's  incision  made  along  the  ridge  of 
the  nose  (Fig.  71,  C),  with  or  without  a  transverse  one  pass- 
ing across  it  and  below  the  margin  of  each  orbit. 

The  bones  are  removed  together,  not  separately.  The 
malar  processes  or  bones  are  divided  in  the  usual  manner, 
the  nasal  processes  divided  with  a  chain-saw  passed  from 
one  orbit  to  the  other  through  the  lachrymal  bones,  and  the 
vomer  separated  with  cutting  forceps.  The  periosteum  of 
the  hard  palate  is  separated  from  the  gums  by  a  semicircu- 
lar incision  and  dissected  back,  the  posterior  connections 
broken,  and  the  bone  removed  by  twisting  it  downward 
and  forward. 


PARTIAL   AND    TEMPORARY   EXCISION   OF  THE  SUPERIOR 

MAXILLA   TO    FACILITATE   THE   REMOVAL   OF 

NASO-PHARYNGEAL    POLYPS. 

Resection  of  Posterior  Portion  of  Hard  Palate  (Nelaton). 
The  soft  palate  is  first  divided  from  before  backward  along 
the  median  line,  and  the  incision  prolonged  forward  through 
the  periosteum  of  the  hard  palate  as  far  as  may  be  judged 
necessary.  A  transverse  incision  is  next  made  on  one  side 
from  the  anterior  extremity  of  the  first  toward  the  teeth, 
and  the  flap,  including  half  the  soft  palate,  dissected  off 
the  bone  from  the  median  line  outward.  The  mucous 
membrane  on  the  floor  of  the  corresponding  nostril  is  then 
divided  close  to  the  septum,  the  bone  perforated  at  the  an- 
terior corners  of  the  denuded  surface,  and  the  separation  of 
the  quadrilateral  piece  accomplished  with  cutting  forceps. 

After  removal  of  the  polyp  the  soft  parts  are  replaced 
and  stitched  together.     The  bone  is  sometimes  reproduced. 

A  little  larger  opening  may  be  obtained  by  making  the 
transverse  incision  extend  from  one  side  of  the  hard  palate 
to  the  other,  and  then  chiselling  away  the  included  bone — 
in  other  words,  nearly  the  whole  of  the  bony  floor  of  the 


170 


OPERATIVE  SURGERY. 


nasal  cavity  (Fig.  72,  A).     At  the  close  of  the  operation 
staphylorrhaphy  is  performed. 

Osteoplastic  Resection  of  the  Anterior  Portion  of  the  Palate 
(Chalot,  Fig.  72,  B).  The  upper  lip  is  everted  and  the 
raucous  membrane  cut  in  the  line  of  its  reflection  from  the 


Fig.  72. 


Resection  of  hard  palate  to  expose  nasal  fossse. 
A.  Nelaton's  operation.  B.  Chalot's  operation. 

bicuspid  teeth  of  one  side  to  a  corresponding  point  on  the 
other — the  nasal  fossa  is  thus  entered,  the  canine  teeth  are 
extracted,  and  the  alveolus  and  hard  palate  divided  on  each 
side  by  the  chisel  and  knife.  The  line  of  section  runs 
through  the  canine  sockets  and  passes  back  through  the 
hard  palate  close  to  its  lateral  margins  as  far  as  its  posterior 


EXCISION  OF  JOINTS  AND  BONES.  171 

border.  The  vomer  is  then  separated,  and  the  quadrilateral 
piece  of  bone  thus  marked  out  is  turned  down,  the  unsev- 
ered  attachments  of  the  soft  palate  serving  as  a  hinge.  At 
the  close  of  the  operation  it  is  replaced  and  sutured  in 
position. 

Resection  of  the  Upper  Portion,  leaving  the  Hard  Palate 
and  Alveolar  Process  (Von  Langenbeck).  The  following 
is  somewhat  abridged  from  the  description  in  the  Deutsche 
Klinik,  1861,  page  283: 

An  incision  convex  downward  from  the  ala  of  the  nose 
to  the  malar  bone,  and  along  the  zygoma  backward.  A 
second  incision  from  the  nasal  process  of  the  frontal  along 
the  lower  border  of  the  orbit,  meeting  the  first  at  the  middle 
of  the  malar  bone  (Fig.  71,  L). 

The  knife  penetrates  to  the  bone  throughout.  The  peri- 
osteum and  overlying  soft  parts  are  only  separated  suffi- 
ciently to  permit  the  use  of  a  saw  or  chisel  along  the  lines 
thus  indicated.  But  the  periosteum  on  the  upper  side  of 
the  second  incision  is  detached  from  the  floor  of  the  orbit 
as  far  back  as  the  spheno-maxillary  fissure. 

Next  the  masseter  is  separated  from  the  exposed  portion 
of  the  malar  bone,  and  a  pointed  elevator  is  passed  hori- 
zontally below  the  zygomatic  arch  and  through  the  ptery go- 
maxillary  fissure  to  the  outer  wall  of  the  nasal  cavity.  It 
is  recognized  here  by  a  finger  introduced  through  the  mouth. 
A  fine  saw  is  passed  in  this  line  and  n.ade  to  cut  through 
the  zygoma  and  malar  bone  upward  into  the  spheno-maxil- 
lary fissure ;  it  then  follows  the  floor  of  the  orbit  and  ends 
just  short  of  the  lachrymal  bone ;  or  the  cut  may  be  made 
with  a  chisel  from  before  backward. 

The  saw  is  then  re-entered  into  the  pterygo-maxillary 
fissure  at  the  outer  extremity  of  the  line  of  bony  division 
at  the  lower  border  of  the  malar  bone,  aud  passing  through 
the  walls  of  the  antrum  very  nearly  in  the  line  ot  the  lower 
cutaneous  incisiou  enters  the  anterior  nares  close  to  the  nasal 
floor.  An  elevator  is  now  passed  a  second  time  into  the 
pterygo-maxillary  fissure,  and  the  portion  of  the  superior 
maxilla  which  has  been  separated  is  forced  up  till  the  free 
portion  of  the  malar  bone  is  brought  into  the  middle  line 
of  the  face.     The  attachments  of  this  fragment  consist  of 


172  OPERATIVE  SURGERY. 

the  nasal  bone  and  the  nasal  process  of  the  superior  maxilla, 
with  the  hitherto  undisturbed  periosteum  and  soft  parts  at 
the  base  of  the  original  tongue-shaped  incision. 

A  less  satisfactory  view  of  the  naso-pharyngeal  region 
is  obtained  if  the  floor  of  the  orbit  is  preserved.  The 
periosteum  on  the  upper  side  of  the  orbital  incision  is  not 
disturbed.  The  zygoma  is  cut  through  as  before  into  the 
spheno-maxillary  fissure.  A  chisel  is  driven  from  before 
backward  in  the  line  of  the  upper  cutaneous  incision  through 
the  anterior  and  outer  walls  of  the  antrum  just  below  the 
orbital  plate,  then  through  these  openings  the  inner  wall  of 
the  antrum  is  divided.  The  chisel  penetrates  to  the  spheno- 
maxillary fossa.  The  lower  line  of  bony  division  is  the 
same  as  in  the  last  method  described,  and  the  fragment  is 
turned  over  in  the  same  manner. 

After  the  completion  of  the  operation  it  is  replaced  and 
maintained  in  position  by  sutures  or  pressure. 

Von  Langenbeck's  operation  is  difficult ;  it  destroys  the 
orbicular  branches  of  the  facial  nerve,  often  damages  the 
lachrymal  duct,  and  gives  very  little  better  view  of  the 
nasal  cavity  than  Guerin's  partial  extirpation  of  the  supe- 
rior maxilla. 


OTHER   METHODS  OF   GAINING  ACCESS  TO  THE  PHARYNX 
THROUGH    THE   NOSE. 

These  may  here  be  described,  although  properly  speak- 
ing they  are  not  resections  of  the  superior  maxilla. 

BoecMs  Operation.  (Fig.  69,  D,  and  Fig.  71,  K.) 
The  incision  begins  near  the  root  of  the  nose  slightly  to  one 
side  of  the  median  line.  It  passes  in  a  curved  direction 
down  to  the  lower  free  border  of  the  nasal  bone ;  from 
here  to  the  junction  of  the  ala  and  cheek  and  a  short  dis- 
tance outward  on  the  cheek.  The  second  incision  passes 
from  the  origin  of  the  first  at  the  root  of  the  nose  along 
the  edge  of  the  orbit  to  the  infra-orbital  foramen.  It  must 
clear  the  lachrymal  sac.  This  tongue-shaped  flap  is  raised 
with  the  periosteum  and  exposes  a  triangular  surface  of 
bone.  After  retracting  the  soft  parts  a  chisel  is  driven 
through  the  superior  maxilla  so  as  to  divide  it  vertically 


EXCISION  OF  JOINTS  AND  BONES. 


173 


just  inside  the  infra-orbital  foramen  between  the  margin 
of  the  orbit  and  the  upper  surface  of  the  hard  palate. 
The  chisel  should  be  obliquely  directed  and  enter  the  nasal 
cavity  near  the  vertical  plate  of  the  palate  bone. 

The  nasal  process  of  the  superior  maxilla  and  the  nasal 
bone  are  cut  very  nearly  in  the  line  of  the  upper  cutaneous 
incision.  The  lachrymal  sac  must  be  spared.  The  bony 
division  is  carried  down  to  the  lower  free  border  of  the 
nasal  bone.  Finally  the  chisel  is  driven  into  the  nasal 
cavity  through  the  anterior  and  inner  walls  of  the  antrum 
on  a  line  reaching  from  the  lower  termination  of  the  first 
bony  incision  to  the  floor  of  the  nose. 

The  inferior  and  middle  turbinated  bones  are  removed 
with  the  mass  thus  marked  out,  which  is  more  or  less 
pyramidal  in  shape  with  the  apex  toward  the  posterior  nares. 

At  the  close  of  the  operation  the  periosteum  and  skin 
are  replaced  and  sutured  in  position. 

Oilier  turns  the  whole  nose  downward.  He  begins  his 
incision  at  the  edge  of  the  bone  close  behind  the  ala  of  the 


Fig.  73. 


Ollier's  operation  for  removal  of  a  naso-  pharyngeal  polyp, 
very  large  polyp. 


B.  Modification  for  a 


nose,  carries  it  upward  along  its  side  to  the  highest  part  of 
the  depression  between  the  eyes,  then  across  and  down  to 
the  corresponding  point  on  the  other  side  (Fig.  73,  ^4). 
The  bone  is  sawn  through  in  the  line  of  the  incision,  the 
necessary  liberating  incisions  made  in  the  septum  or  the 
sides,  and  the  nose  turned  down. 


174  OPERATIVE  SURGERY. 

The  septum  is  pressed  aside,  the  polyp  extracted,  its  base 
of  implantation  scraped,  and  the  nose  replaced. 

A  modification  which  is  sometimes  desirable  on  account 
of  the  size  of  the  polyp  or  the  distance  of  its  implantation 
is  indicated  in  Fig.  73,  B.  The  incision  runs  more  ob- 
liquely backward,  and  a  transverse  one  is  made  from  each 
end  to  the  ala  of  the  nose.  The  bone  is  divided  in  the 
direction  of  the  cutaneous  incisions,  in  the  vertical  one  as 
before  described,  in  the  horizontal  one  by  passing  a  fine  saw 
across  the  nostrils  through  holes  made  between  the  bone 
and  cartilages,  and  sawing  backward.  This  line  of  section 
must  be  high  enough  to  avoid  the  roots  of  the  teeth. 

In  some  cases  it  is  sufficient  to  mobilize  the  lower  end  of 
the  nose  by  an  incision  under  the  lip  in  the  gingivo-labial 
fold,  and  then  by  carrying  it  and  the  lip  upward  very  free 
access  to  the  nasal  fossse  is  obtained. 

Annandale,1  after  turniug  the  lip  and  nose  upward  in  this 
fashion,  saws  through  the  alveolus  and  hard  palate  in  the 
middle  line  close  to  one  side  of  the  vomer.  The  soft  palate 
may  also  be  split  if  more  space  is  required.  The  saw  cut 
can  then  be  made  half  an  inch  or  more  wide  by  prying 
apart  the  maxillae.  This  affords  a  somewhat  limited  means 
of  access  to  the  naso-pharyngeal  region. 

EXCISION   OF  THE   INFERIOR   MAXILLA. 

This  may  be  total  or  partial ;  and  partial  excision  may 
involve  the  removal  of  any  part  of  the  body  of  the  bone  or 
of  the  ascending  ramus.  Partial  excision  of  the  body  may 
sometimes  be  accomplished  through  the  mouth  without  the 
aid  of  a  cutaneous  incision,  or  by  an  incision  along  the 
lower  border  of  the  bone  with  or  without  another  at  right 
angles  to  it  extending  toward  or  even  through  the  lip,  or 
by  two  vertical  incisions  downward  from  the  angles  of  the 
mouth  when  only  the  upper  part  of  the  body  of  the  bone  is 
to  be  removed. 

When  the  ascending  ramus  also  is  to  be  resected  the  in- 
cision should  pass  along  the  lower  border  of  the  bone  to  the 
angle  of  the  jaw,  and  then  upward  along  the  posterior 

1  Lancet,  Jan.  5, 1889. 


EXCISION  OF  JOINTS  AND  BONES.  175 

border  of  the  ramus  to  the  level  of  the  lobule  of  the  ear. 
If  the  incision  is  carried  higher  the  facial  nerve  is  neces- 
sarily divided  with  consequent  paralysis  of  the  muscles 
supplied  by  it,  a  complication  which  should  be  avoided. 
The  horizontal  portion  of  the  incision  should  be  a  little 
below  the  border  of  the  bone  in  order  that  the  cicatrix 
may  be  less  conspicuous.  Syme  removed  the  entire  ramus 
with  the  condyle,  without  opening  into  the  cavity  of  the 
mouth,  by  an  incision  slightly  convex  backward  extending 
from  the  zygoma  to,  and  a  little  beyond,  the  angle  of  the  jaw. 

The  principal  danger  is  of  injury  to  the  internal  maxil- 
lary artery,  which  lies  almost  in  contact  with  the  inner  side 
of  the  neck  of  the  condyle.  The  lingual  nerve  also  is  in 
close  relation  with  the  inner  side  of  the  ramus,  lying  be- 
tween it  and  the  internal  pterygoid  muscle.  Maisonneuve 
introduced  a  modification  of  the  method  of  operating  which 
has  rendered  it  almost  easy  and  has  diminished  the  above- 
mentioned  danger.  It  consists  in  separating  the  attach- 
ments of  the  condyle  by  twisting  and  tearing  out  the  bone 
after  all  the  connections  have  been  divided.  If  this  modi- 
fication, which  sounds,  perhaps,  rougher  and  less  surgical 
than  it  really  is,  is  not  adopted,  the  joint  must  be  ap- 
proached from  in  front  so  as  to  avoid  the  external  carotid, 
which  lies  close  behind  the  bone  in  the  substance  of  the 
parotid.  It  is  sometimes  allowable  to  divide  the  neck  of 
the  condyle,  or  even  the  ramus  below  the  sigmoid  notch, 
with  cutting  pliers,  and  leave  the  upper  fragment  in  place. 

Another  danger  is  in  the  division  of  the  attachments  of 
the  genio-hyo-glossus  muscles  to  the  bone.  The  tongue,  de- 
prived of  its  support,  falls  back  upon  and  closes  the  glottis. 
As  a  preliminary,  therefore,  to  any  operation  in  which  these 
attachments  are  divided,  a  stout  ligature  should  be  passed 
through  the  tip  of  the  tongue  and  held  by  an  assistant. 
After  the  operation  it  should  be  fastened  to  a  harelip  pin 
in  the  external  incision,  or  to  the  skin  of  the  face  by  a  strip 
of  adhesive  plaster,  and  retained  for  a  couple  of  days,  at 
the  end  of  which  time  the  muscles  will  usually  have  formed 
new  attachments. 

The  bone  should  be  sawn  through  with  a  chain  or  com- 
mon saw,  according  to  circumstances,  or  merely  nicked  with 
the  saw,  and  its  division   completed  with   cutting-pliers, 


176  OPERATIVE  SUBGERY. 

The  tooth  occupying  the  proposed  line  of  section  should 
first  be  drawn. 

Ligature  of  one  or  both  carotids  has  been  proposed  and 
performed  as  a  preliminary  operation  to  prevent  excessive 
hemorrhage,  but  it  has  proved  to  be  not  only  unnecessary 
but  ineffectual.  In  Mott's  case  the  main  operation  had  to 
be  adjourned  to  allow  the  patient  to  recover  from  the  shock 
of  the  preliminary  one.  In  another  case  in  which  both 
carotids  had  been  tied,  the  main  operation  had  to  be  aban- 
doned on  account  of  hemorrhage.1  Syme  says  the  pre- 
liminary ligation  is  unnecessary,  because  the  only  arteries 
that  need  to  be  divided  are  the  facial  and  the  transverse 
branches  of  the  temporal,  bleeding  from  which  can  be  easily 
controlled,  and,  furthermore,  all  the  advantages  offered  by 
ligation  of  the  carotids  can  be  obtained  by  their  temporary 
compression  during  the  operation. 

The  attempt  should  be  made,  when  possible,  to  get  pri- 
mary union  of  the  intra-buccal  wound  and  to  drain  through 
the  external  one.  This  makes  it  easier  to  keep  the  wound 
sweet,  diminishes  the  danger  of  purulent  infection,  and 
avoids  the  risks  incident  to  the  swallowing  of  the  decom- 
posing discharges. 

The  results  of  the  operation  are  usually  very  good,  and 
the  deformity  less  than  might  be  expected.  Subperiosteal 
excision  has  been  followed  by  reproduction  of  the  entire 
bones  with  condyles  and  diarthrodial  cartilages,  and  even 
when  the  periosteum  is  not  preserved  the  cicatrix  becomes 
very  firm  and  fibrous,  and  able  to  support  a  plate  with  arti- 
ficial teeth. 

Resection  of  the  Anterior  Portion  of  the  Body.  This 
may  be  done  by  means  of  a  vertical  incision  in  the  median 
line,  or  of  a  horizontal  one  below  the  free  border  of  the 
bone,  or  from  within  the  mouth  without  any  cutaneous 
incision. 

If  one  of  the  incisions  is  made,  the  external  and  internal 
surfaces  of  the  bone  are  cleared  through  it,  a  tooth  drawn 
at  each  of  the  proposed  points  of  section,  and  the  bone  sawn 
through. 

1  Mentioned  by  Syme  in  Contributions  to  the  Pathology  and  Practice  of  Sur- 
gery, Edinb.,  1848,  p.  19. 


EXCISION  OF  JOINTS  AND  BONES.  177 

If  no  external  incision  is  made,  the  external  surface  of 
the  bone  is  cleared,  beginning  at  the  edge  of  the  gum  or  in 
the  giugivo-labial  fold,  according  as  the  periosteum  is  or  is 
not  to  be  preserved,  and  the  lip  drawn  down  under  the 
chin  so  that  the  bone  protrudes  through  the  mouth.  It 
can  then  be  easily  sawn  through  and  freed  from  its  attach- 
ments on  the  inner  side. 

Resection  of  the  Lateral  Portion  of  the  Body.  The  in- 
cision extends  along  the  lower  border  of  the  jaw  from  its 
angle  nearly  to  the  symphysis,  and  then  is  carried  vertically 
upward  to  the  base  of,  but  not  through,  the  lip.  The  flap 
is  dissected  up,  the  elevator  being  used,  of  course,  if  the 
periosteum  is  to  be  preserved,  the  inner  surface  of  the  bone 
cleared  near  the  symphysis  for  the  passage  of  a  chain-saw, 
and  the  section  made  if  possible  at  a  short  distance  from 
the  median  line,  so  as  not  to  disturb  the  insertion  of  the 
genio-hyo-glossus.  This  section  may  be  made  with  a  nar- 
row saw  from  before  backward  if  preferred. 

The  bone  is  then  drawn  downward  and  outward,  its  inner 
surface  cleared,  and  the  saw  applied  behind  the  last  molar 
tooth  or  at  any  suitable  point. 

Dr.  McBurney1  has  devised  a  remarkably  efficient  means 
of  maintaining  the  proper  relations  of  the  remaining  por- 
tions to  each  other  until  repair  has  taken  place,  and  of 
thereby  avoiding  the  great  interference  with  function  which 
formerly  ensued. 

Resection  of  the  Ramus  and  Half  of  the  Body.  (Fig. 
74.)  An  incision  is  begun  close  to  the  posterior  border  of 
the  ramus  on  a  level  with  the  lobule  of  the  ear,  carried 
down  to  the  angle  of  the  jaw,  and  thence  along  its  lower 
border  to  the  symphysis,  where  it  is  met,  if  necessary,  by 
a  vertical  one,  beginning  below  the  free  border  of  the  lip  a 
little  to  that  side  of  the  median  line  on  which  the  bone  is 
to  be  removed.  The  flap  thus  marked  out  is  dissected  up 
from  the  bone  as  far  as  can  be  done  without  opening  into 
the  buccal  cavity,  and  the  divided  facial  artery  tied.  The 
inner  surface  of  the  bone  is  then  cleared  in  the  same  man- 
ner, an  incisor  tooth  drawn,  and  the  bone  sawn  through. 

1  Annals  of  Surgery,  1S94. 


178 


OPERATIVE  SUBQERY. 


The  jaw  is  then  drawn  downward  and  forward,  the  denu- 
dation of  its  inner  surface  completed  by  dividing  the  attach- 
ment of  the  mucous  membrane  and  of  the  internal  ptery- 
goid, and  the  inferior  dental  nerve  cut  squarely  across  at 
the  point  where  it  enters  the  bone. 


Fig.  74. 


Excision  of  inferior  maxilla. 

The  insertion  of  the  temporal  muscle  upon  the  coronoid 
process  is  divided  with  curved  scissors  while  the  jaw  is 
forcibly  depressed,  or  the  process  itself  is  cut  through  if  it 
is  so  long  that  its  extremity  cannot  be  reached. 

The  remaining  soft  parts  are  carefully  detached  upward 
toward  the  condyle,  the  knife,  or  better,  the  elevator  or  the 
handle  of  the  scalpel,  being  kept  close  to  the  bone,  and  the 
separation  completed  by  twisting  the  jaw  out. 

Excision  of  the  whole  of  the  Inferior  Maxilla.  The  in- 
cision is  made  from  the  lobule  of  one  ear  down  to  the  angle 
of  the  jaw,  along  the  lower  border  of  the  bone  to  the  other 
angle,  and  then  up  to  the  lobule  of  the  other  ear.  The 
outer  and  inner  surfaces  of  the  jaw  arc  denuded,  the  bone 
sawn  through  in  the  median  line,  and  each  half  removed  as 
before  described. 

In  the  subperiosteal  method  the  incisions  are  the  same, 
except  that  the  vertical  incision  may  be  in  the  median  line, 


EXCISION  OF  JOINTS  AND  BONES.  179 

since  the  genio-hyo-glossus  and  genio-hyoid  muscles  remain 
attached  to  the  periosteum.  The  attachment  of  the  tem- 
poral muscle  is  not  cut,  but  is  freed  with  the  elevator,  as  is 
also  that  of  the  external  pterygoid  to  the  condyle. 

Partial  Excisions  of  the  Inferior  Maxilla.  Removal  of 
a  portion  of  the  alveolar  process  is  often  necessary  in  the 
operation  for  epulis.  The  teeth  in  the  involved  segment 
are  drawn.  The  muco-periosteum  at  a  sufficient  distance 
from  the  growth  is  cut  through  and  the  bony  segment  thus 
marked  out  removed  through  the  mouth  with  a  chisel  or 
rongeur. 

If  a  portion  of  the  body  of  the  jaw  is  to  be  removed  it 
should  be  approached  by  an  incision  along  the  lower  border 
of  the  maxilla.  Whenever  possible  the  removal  should  be  so 
limited  as  not  wholly  to  destroy  the  continuity  of  the  bone. 

The  part  represented  in  Fig.  69  is  the  ordinary  amount 
removed  for  epulis,  and  it  can  be  accomplished  through 
the  mouth. 

ANCHYLOSIS   OF  THE   JAW. 

The  most  common  cause  of  anchylosis  of  the  jaw  is 
fouud  in  cicatricial  retraction  or  adhesions  left  behind  by 
intra  buccal  ulceration.  Rizzoli  (1858)  was  the  first  to 
point  out  that  the  proper  aim  of  an  operation  intended  to 
relieve  this  infirmity  should  be  the  establishment  of  a  pseud- 
arthrosis  in  front  of  the  adhesions  or  cicatricial  bands  when 
the  cause  itself  could  not  be  removed.  His  operation  con- 
sisted in  the  division  of  the  inferior  maxilla  behind  the  last 
molar  tooth  by  means  of  a  specially  constructed  osteotome 
introduced  through  the  mouth.  Bony  union  of  the  fracture 
was  then  to  be  preveuted  by  motion.  Esmarch  (1859) 
proposed  the  removal  of  a  wedge-shaped  piece  of  the  bone. 
By  some  surgeons  the  base  of  the  wedge  is  taken  from  the 
alveolar  process,  by  others  from  the  lower  border  of  the 
jaw.  Dieffenbach  proposed  to  divide  the  ascending  ramus 
horizontally  from  before  backward  by  means  of  a  chisel 
passed  through  the  mouth  to  the  anterior  border  of  the 
ramus. 

Operation  (removal  of  wedge-shaped  piece).    An  incision 


180  OPERATIVE  SURGERY. 

is  begun  at  the  angle  of  the  jaw  and  carried  two  inches  for- 
ward along  the  lower  border.  A  narrow  strip  of  bone  is 
then  cleared  on  both  sides  up  to  the  edge  of  the  gum,  just 
anterior  to  the  inasseter  and  in  front  of  the  contracted  tis- 
sues, a  tooth  drawn  if  necessary,  and  the  bone  sawed 
through.  The  anterior  fragment  is  then  depressed  and 
protruded  through  the  wound,  and  a  wedge-shaped  piece 
from  one-third  to  one-half  of  an  inch  in  width  at  its  widest 
part  cut  off  with  cutting  forceps.     (Fig.  69,  I.) 

Excision  of  the  Condyle.  This  may  be  required  for  the 
relief  of  anchylosis  due  to  bony  or  fibrous  union  between 
the  condyle  and  the  temporal  bone.  The  incision  is  begun 
at  the  lower  margin  of  the  zygoma  close  in  front  of  the 
temporal  artery  where  it  adjoins  the  ear,  and  carried  forward 
along  the  zygoma  about  one  and  a  quarter  inches,  the  tissues 
being  divided  layer  by  layer  until  the  bone  is  reached.  A 
second  incision,  involving  only  the  skin,  is  then  carried 
from  the  centre  of  the  first  directly  downward  for  about  an 
inch.  The  soft  parts  are  next  carefully  separated  with  knife 
and  elevator  from  the  margin  of  the  zygoma  and  the  outer 
surface  of  the  joint  and  drawn  downward  with  a  hook, 
thus  preserving  the  parotid,  nerves,  and  vessels  from  injury. 
The  neck  of  the  condyle  is  then  freed  by  working  around 
in  front  and  behind  with  a  small  elevator,  keeping  close  to 
the  bone,  so  as  to  avoid  injury  to  the  internal  maxillary 
artery,  and  finally  divided  with  the  chisel  and  rongeur.  If 
there  is  bouy  union  between  the  condyle  and  temporal  bone 
the  chisel  must  be  again  used  to  separate  them,  its  edge 
being  kept  directed  somewhat  downward,  so  as  not  to  break 
through  into  the  cavity  of  the  cranium.  The  condyle  is 
then  grasped  with  forceps  and  twisted  out.  The  knife  or 
scissors  may  be  used  to  sever  any  remaining  connections, 
but  must  be  kept  close  to  the  bone. 

RESECTION    OF   THE   STERNUM. 

Oilier1  reports  the  following  case  :  Vertical  incision  four 
inches  long ;  detachment  of  periosteum,  and  removal  of  a 

1  Traite  de  la  R6g6n6ration  des  Os,  vol.  ii.  p.  53. 


EXCISION  OF  JOINTS  AND  BONES.  \  81 

"  red  vascular  sequestrum  one  and  one-quarter  inches  square, 
adherent  to  the  rest  of  the  bone  only  by  medullary  granu- 
lations." The  adjoining  rarefied  bone  was  gouged  away, 
portions  of  the  internal  plate  being  left  at  a  few  points. 
The  projecting  and  denuded  ends  of  two  costal  cartilages, 
the  fourth  and  fifth,  were  cut  off. 

Three  years  afterward  the  patient  died  of  phthisis,  and 
the  autopsy  showed  reproduction  of  all  the  parts  removed. 


RESECTION    OF   THE    RIBS. 

This  is  best  performed  in  those  regions  where  the  muscu- 
lar layer  covering  the  bone  is  thin.  In  the  middle  third  of 
the  rib  the  intercostal  artery  lies  in  a  groove  on  the  inner 
side  of  the  lower  border. 

The  incision  should  correspond  in  length  and  direction 
with  the  portion  of  bone  to  be  removed,  and  may  be  crossed 
at  each  end  by  a  short  transverse  one.  The  flaps  are  then 
dissected  up,  the  periosteum  separated  as  far  as  possible,  a 
chain-saw  passed  at  the  limits  of  the  diseased  portion,  and 
the  piece  removed.  Instead  of  the  saw,  cutting-pliers  may 
be  used. 

In  Estlander's  operation  for  empyema  (thoraco-plastik), 
in  which  portions  of  several  adjoining  ribs  are  resected  to 
allow  the  chest  wall  to  sink  inward  and  unite  with  the  vis- 
ceral pleura,  the  position  of  the  incision  is  usually  deter- 
mined by  that  of  the  fistula.  The  incision  is  made  along 
the  intercostal  space  occupied  by  the  fistula,  and  the  adjoin- 
ing ribs  dissected  as  above  described.  The  limits  of  the 
cavity  are  then  determined,  and  other  ribs  resected,  if 
necessary,  through  a  vertical  incision  made  from  the  centre 
of  the  first.  If  the  costal  pleura  is  so  thick  as  to  prevent 
the  attainment  of  the  desired  object,  it  must  be  cut  away 
from  a  sufficient  part  of  the  area  of  resection.  From  three 
to  six  ribs  have  been  thus  resected,  in  lengths  varying  from 
one  to  three  inches.  The  operation  has  been  restricted  to 
the  ribs  between  the  third  and  eighth,  but  in  one  case  a 
small  portion  of  the  clavicle  also  was  removed.  Sometimes 
the  thickened  visceral  pleura  has  also  been  dissected  off. 


182  OPERATIVE  SURGERY. 


EXCISION   OF   THE   CLAVICLE. 

On  account  of  the  proximity  of  the  large  vessels  of  the 
neck  this  has  been  considered  the  most  dangerous  of  all  the 
excisions.  The  danger,  however,  varies  greatly  with  the 
nature  and  extent  of  the  disease  which  renders  the  opera- 
tion necessary.  Thus,  when  there  is  osteitis  with  thicken- 
ing and  loosening  of  the  periosteum,  the  operator  can  easily 
keep  close  to  the  bone,  and  the  danger  of  injury  to  the 
vessels,  as  well  as  of  exciting  diffuse  inflammation  below 
the  deep  fascia,  is  reduced  to  the  minimum.  On  the  other 
hand,  when  caries  has  existed  for  a  long  time,  the  soft  parts 
have  become  infiltrated  and  bound  down,  and  the  bone 
thickened  and  roughened,  the  difficulties  are  immensely 
increased ;  and  when  the  bone  is  the  seat  of  a  malignant 
tumor,  extending  in  all  directions,  its  removal  may  tax  the 
powers  of  the  most  skilful.  Valentine  Mott  spoke  of  his 
case  as  the  most  difficult  and  tedious  operation  he  had  ever 
witnessed  or  performed ;  it  lasted  four  hours,  and  more 
than  forty  ligatures  were  applied,  including  two  upon  the 
internal  jugular  vein. 

As  only  the  inner  half  of  the  bone  is  in  close  relation 
with  the  vessels,  and  the  danger  is  especially  great  at  the 
sterno-clavicular  joint,  it  is  advisable  first  to  raise  the  outer 
end  of  the  bone  from  its  place  by  opening  its  articulation 
with  the  acromion  or  by  dividing  it  a  little  to  the  inner  side 
of  that  joint,  and  then,  after  clearing  the  posterior  surface 
from  without  inward,  to  divide  the  attachments  ot  the  inner 
end  while  twisting  the  bone  upward  about  its  long  axis, 
and  keeping  the  edge  of  the  knife  against  it.  When  this 
is  impracticable  the  periosteum  must  be  carefully  separated 
near  the  middle,  and  the  bone  sawn  through  with  the  usual 
precautions  against  injury  to  the  underlying  parts.  Each 
half  is  then  raised  in  turn  and  dissected  out. 

For  the  removal  of  a  tumor  no  fixed  rules  can  be  given. 
In  other  cases  the  directions  are  as  follows  : 

Operation.  The  subperiosteal  method  must  be  employed 
throughout.  The  incision  is  made  along  the  anterior  sur- 
face of  the  bone,  and  corresponds  in  length  with  the  portion 
to  be  removed.     A  short  transverse  incision  is  then  made 


EXCISION  OF  JOINTS  AND  BONES.  183 

at  each  end  of  the  first,  the  flaps  dissected  up,  and  the 
denudation  carried  as  far  as  possible  around  the  bone  above 
and  below. 

The  bone  is  then  freed  at  its  acromial  end,  or  divided  in 
the  middle,  and  the  separation  completed  as  above  described. 


EXCISION   OF   THE  SCAPULA. 

It  is  impossible  to  lay  down  fixed  rules  for  making  the 
incisions  when  the  operation  is  rendered  necessary  by  a 
tumor  of  the  bone.  They  will  be  determined  by  the  cir- 
cumstances of  the  case,  and  especially  by  the  extent  of  the 
disease,  for  while  in  some  cases  the  acromial  end  of  the 
clavicle  must  also  be  removed,  in  others  the  acromion  and 
neck  of  the  scapula  may  be  left  behind. 

Mr.  Holmes1  says  :  "  The  surgeon  turns  down  appro- 
priate skin  flaps.  .  .  .  When  the  whole  tumor  is  thus 
exposed,  the  muscles  inserted  into  the  vertebral  border  of 
the  bone  should  be  rapidly  divided,  as  also  those  which  are 
attached  to  the  spine  of  the  scapula.  The  tumor  should  be 
lifted  well  up  and  freed  from  its  other  attachments,  com- 
mencing from  its  lower  angle.  The  subscapular  artery  is 
divided  near  the  end  of  the  operation,  and  can  be  held  till 
the  tumor  is  removed,  or  can  be  at  once  tied.  The  liga- 
ments of  the  shoulder  are  then  easily  divided  and  the  mass 
removed." 

Gross2  made  a  vertical  incision  sixteen  inches  long  down- 
ward from  the  superior  angle  of  the  scapula,  and  circum- 
scribed an  oval  portion  by  a  second  curved  incision,  begin- 
ning five  inches  below  the  upper  end  of  the  first  and  ending 
about  the  same  distance  above  its  lower  end,  and  removed 
the  bone  after  sawing  through  the  acromion  and  neck  of  the 
scapula. 

Velpeau3  recommends  three  incisions  :  one  along  the  spine 
of  the  scapula,  the  others  starting  from  the  anterior  extrem- 
ity of  the  first  and  running,  one  toward  the  root  of  the  neck, 
the  other  toward  the  axilla  behind. 

1  A  System  of  Surgery,  vol.  v.  p.  669. 

2  Gross's  System  of  Surgery,  vol.  ii.  p.  1078. 

3  Medicine  Operatoire,  vol.  ii.  p.  659. 


184  OPERATIVE  SURGERY. 

Sytne  made  two  incisions  crossing  each  other  near  the 
centre  of  the  tumor.  Other  surgeons  have  made  triangular 
or  semilunar  flaps. 

In  January,  1878,  Dr.  George  A.  Peters  removed,  at  the 
New  York  Hospital,  the  entire  scapula  for  malignant  dis- 
ease, leaving  the  arm.  He  made  an  incision  along  the  spine 
of  the  scapula,  divided  the  fibres  of  the  deltoid  and  trape- 
zius, and  exposed  the  tumor,  which  involved  only  the  acro- 
mion and  adjoining  portion  of  the  spine.  He  then  made  a 
vertical  incision  across  the  centre  of  the  first,  beginning  two 
inches  above  it  and  extending  to  the  inferior  angle  of  the 
scapula,  reflected  the  flaps,  dissected  out  the  under  surface 
of  the  boue  from  behind  forward,  separated  the  acromion 
from  the  clavicle  and  humerus,  and  then,  raising  the  lower 
angle  of  the  scapula  toward  the  head,  approached  the  cora- 
coid  process  from  below,  and  found  no  difficulty  in  sepa- 
rating it  from  its  attachments.  Only  two  vessels  required 
ligation,  the  supra-scapular  aud  a  large  branch  of  the  sub- 
scapular. The  result  was  very  good  ;  six  weeks  afterward 
the  wound  had  closed,  and  the  patient  possessed  a  certain 
degree  of  control  over  the  humerus. 

Subperiosteal  Excision  of  the  Scapula  (Oilier).  Fig.  75. 
1 .  Incision  of  the  Skin  and  Muscular  Interstices.  An  inci- 
sion is  made  along  the  whole  length  of  the  spine  of  the 
scapula,  and  from  its  posterior  extremity  two  others  are 
made,  one  following  the  posterior  border  down  to  the  infe- 
rior angle,  the  other  running  obliquely  forward  aud  upward 
for  about  an  inch.  A  short  transverse  incision  may  also  be 
needed  at  the  anterior  end  of  the  first. 

2.  Denudation  of  the  Bone.  The  attachments  of  the  del- 
toid and  trapezius  to  the  acromion  and  spine  are  separated, 
the  periosteum  of  the  posterior  border  of  the  scapula  divided 
in  the  interstice  between  the  rhomboideus  and  infra-spinatus, 
and  the  infra-spinous  fossa  carefully  denuded.  The  peri- 
osteum is  very  thin  in  its  lower  third.  The  lower  angle  is 
freed  by  detaching  the  teres  major  and  serratus  magnus, 
the  bone  raised,  and  the  subseapularis  detached  from  below 
upward.  I  f  the  marginal  cartilage  is  not  completely  ossified 
and  united  with  the  bone,  it  should  be  separated  and  left 
adherent  to  the  periosteum. 


EXCISION  OF  JOINTS  AND  BONES. 


185 


The  supra-spinous  fossa  is  then  cleared,  care  being  taken 
not  to  injure  the  supra-scapular  nerve  in  the  supra-scapular 
notch,  but  to  raise  it  up  with  the  periosteum  and  its  fibrous 
sheath.  The  posterior  part  of  the  bone  is  then  carried  up- 
ward and  forward,  and  the  denudation  of  its  under  surface 
and  anterior  border  completed. 

If  the  extent  of  the  disease  permits,  the  denudation  should 
stop  at  the  neck  of  the  scapula,  which  is  then  divided  with 
a  chain-saw  or  cutting  forceps. 


Fig.  75. 


Excision  of  the  scapula. 


3.  Opening  of  the  Scapulo-humeral  Joint.  Detachment 
oj  the  Articular  Capsule  and  Denudation  of  the  Coracoid 
Process.  The  acromion  is  next  separated  from  the  clavicle, 
the  scapula  turned  upward,  the  joint  opened  from  below, 
and  as  the  bone  is  pressed  steadily  upward  everything  that 
holds  is  detached  with  an  elevator.  After  the  coracoid 
process  has  been  thus  separated  from  most  of  its  muscular 
and  ligamentary  attachments,  the  few  that  remain  can  be 
broken  by  twisting  the  bone  away.  In  suitable  cases  the 
coracoid  process  may  be  divided   at  its  base  and   left  in 


186  OPERATIVE  SURGERY. 

place,  and  thus  the  most  difficult  and  laborious  part  of  the 
operation  done  away  with. 

The  partial  excisions  of  the  scapula  do  uot  require  de- 
tailed description.  The  acromion,  spine,  and  posterior  bor- 
der are  reached  by  straight  or  slightly  curved  incisions 
along  the  portion  to  be  removed.  A  crucial  or  H  incision 
is  required  at  the  angles. 


RESECTION   OF   THE   HUMERUS. 

The  position  of  the  musculo-spiral  nerve  is  the  most  im- 
portant element  in  this  operation.  In  its  passage  around 
the  posterior  aspect  of  the  humerus  the  nerve  lies  close  to 
the  bone  within  the  sheath  of  the  triceps  muscle,  and  leaves 
the  latter  on  the  outer  side  of  the  arm  to  enter  that  of  the 
supinator  longus  at  its  origin.  In  approaching  the  bone, 
therefore,  on  the  outer  side  near  the  junction  of  the  middle 
and  lower  thirds,  the  operator  should  lay  bare  the  outer 
border  of  the  brachialis  anticus  and  follow  down  within  its 
sheath  to  the  bone. 

Upper  Portion.  Same  incision  as  in  Oilier' s  method  of 
excision  of  the  shoulder  carried  further  down  along  the 
outer  edge  of  the  biceps.  The  cephalic  vein  must  be  sought 
for  and  drawn  aside.  Periosteum  and  capsule  divided,  bone 
denuded  and  removed  as  in  excision  of  the  shoulder-joint 
(q.  v.). 

Middle  Portion.  Incision  along  the  posterior  border  of 
the  deltoid  and  outer  edge  of  the  biceps.  Outer  border  of 
the  brachialis  anticus  laid  bare  and  followed  down  to  the 
bone.  Division  of  the  periosteum  and  denudation  of  the 
bone,  with  especial  care  for  the  safety  of  the  musculo-spiral 
nerve. 

Oilier  prefers  to  seek  the  nerve  and  draw  it  aside.  He 
also  recommends  that  whenever  it  is  possible  to  leave  a  por- 
tion of  the  shaft  connecting  the  extremities  it  should  be 
done,  as  a  precaution  against  shortening  and  the  formation 
of  a  pseudarthrosis.  If  this  is  not  possible  the  chain- 
saw  is  passed  at  two  points,  and  the  intermediate  piece 
removal. 

Lower  Portion.     Incision  on  outer  side  of  the  posterior 


EXCISION  OF  JOINTS  AND  BONES.  187 

aspect  of  the  arm,  between  the  triceps  and  supinator  longus, 
as  in  Oilier' s  excision  of  the  elbow  (q.  v.). 

Total  Excision.  Combination  of  incisions  for  upper  and 
lower  portions.  After  the  ends  have  been  denuded  of  peri- 
osteum the  middle  portion  can  be  cleared  by  pushing  one 
end  out  through  its  incision  and  peeling  the  periosteum  back 
like  the  finger  of  a  glove  until  the  middle  is  reached.  The 
bone  is  then  sawn  off,  and  the  other  half  removed  in  a  sim- 
ilar manner  through  the  other  incision. 


EXCISION   OP  THE   ULNA. 

Longitudinal  incision  along  the  posterior  aspect  of  the 
bone,  joined  at  its  upper  end  by  a  short  one  running  ob- 
liquely upward  and  outward  between  the  triceps  and  anco- 
neus. The  triceps  is  drawn  to  the  inner  side,  and  the 
olecranon  freed.  After  separation  of  the  periosteum  the 
bone  is  sawn  through  in  the  middle,  and  each  piece  is  dis- 
sected out  in  turn. 


EXCISION   OF   THE   RADIUS   (OLLIEE). 

An  incision  involving  the  skin  only  is  made  from  the 
styloid  process  of  the  radius  along  the  outer  border  of  the 
forearm  to  the  radio-humeral  articulation.  The  fascia  is 
divided  and  the  posterior  border  of  the  supinator  longus 
found.  By  following  it  toward  the  wrist  the  knife  can  be 
kept  between  it  and  the  extensor  tendons  of  the  thumb, 
which  can  then  be  drawn  backward  and  saved  from  injury. 
By  following  it  upward  the  interstice  between  it  and  the 
extensores  carpi  radiales  is  found,  through  which  the  oper- 
ator penetrates  to  the  radius  now  covered  only  by  the 
supinator  brevis.  The  latter  muscle  is  then  divided  longi- 
tudinally and  the  periosteal  sheath  opened. 

The  periosteum  is  detached  laterally,  the  bone  sawn 
through  at  its  middle,  and  each  fragment  removed  sepa- 
rately. 

Partial  Excisions  of  the  Ulna  and  Radius.  The  incisions 
and  methods  are  the  same  as  those  above  described, 


188  OPERATIVE  SUEGERY. 


EXCISION  OF  THE  METACARPAL  BONES  AND  PHALANGES. 

The  metacarpal  bones  should  be  exposed  by  a  longitu- 
dinal incision  along  the  dorsum.  As  the  extensor  tendons 
cross  the  bones  obliquely  this  incision  should  involve  ouly 
the  skin  at  first,  the  tendou  is  then  drawn  aside,  and  the 
iucisiou  carried  down  to  and  through  the  periosteum,  which 
must  be  retained  when  possible.  It  is  advisable  that  the 
joints,  especially  the  rnetacarpo-phalangeal,  should  not  be 
opened. 

The  bone  is  then  divided  in  the  middle  with  cutting  for- 
ceps and  each  end  dissected  out,  or  the  gouge  alone  may 
be  used. 

The  after-treatment  is  important.  Extension  must  be 
made  upon  the  corresponding  finger  for  a  long  time  to  keep 
it  from  being  drawn  up  into  the  hand.  In  the  case  of  the 
metacarpal  bone  of  the  thumb  lateral  pressure  must  also  be 
made. 

For  resection  of  a  phalanx  the  incision  should  be  made 
on  the  side  of  the  finger  near  the  dorsum.  For  the  ter- 
minal phalanx  the  incision  should  be  U-shaped,  the  arms 
passing  along  the  sides  of  the  phalanx,  the  curve  around 
its  end. 

Resection  of  the  different  portions  of  the  thumb,  even  if 
not  subperiosteal,  is  to  be  preferred  to  amputation,  but  the 
contrary  is  true  of  the  phalanges  of  the  other  fingers. 

Lateral  pressure,  by  means  of  splints  or  an  India-rubber 
glovefinger,  and  extension  by  weight  must  be  made  to  insure 
the  necessary  length  and  proper  shape  of  the  member. 


RESECTION   OF  THE   BONES   OF   THE   PELVIS. 

Oilier1  reports  a  case  in  which  he  removed  the  ascending 
ramus  of  the  ischium  and  most  of  the  pubis  for  suppurative 
osteo-arthritis  of  these  bones  and  the  pubic  synchondrosis. 
The  incision  was  about  four  inches  long  and  extended  from 
a  fistula  in  thegenito-crural  fold  up  toward  the  pubis.    The 

1  De  la  K6gC-n6ration  des  Ob,  vol.  ii.  p.  ISO. 


EXCISION  OF  JOINTS  AND  BONES.'  189 

periosteum  was  detached,  the  ascending  ramus  of  the  ischium 
removed,  and  then  the  ascending  ramus,  body,  and  part  of 
the  horizontal  ramus  of  the  pubis.  The  bone  that  was 
removed  was  eroded  and  rarefied,  but  not  necrotic. 


EXCISION  OF  THE   COCCYX   (OLLIER). 

This  may  be  required  on  account  of  disease  of  the  coccyx, 
or  as  a  preliminary  to  operations  upon  the  rectum.  Oilier 
has  removed  it  for  osteitis,  Simpson  and  Nott  for  the  relief 
of  coccygodynia,  and  Verneuil  in  cases  of  imperforate  anus, 
and  to  facilitate  the  removal  of  cancers  of  the  rectum. 

The  limits  of  the  bone  are  determined  by  the  finger  in  the 
rectum,  and  a  longitudinal  incision  made  through  the  skin 
and  fibrous  covering  of  the  bone,  from  a  quarter  of  an  inch 
above  its  upper  to  the  same  distance  below  its  lower  end, 
and  a  transverse  incision  made  at  the  upper  end  of  the  first. 
The  posterior  surface  of  the  bone  is  then  denuded. 

The  sacro-coccygeal  articulation  haviug  been  opened  by 
this  denudation,  its  fibro-cartilage  is  divided,  and  the  cornua 
cleared  on  both  sides.  An  elevator  is  then  passed  through 
the  joint  and  used  as  a  lever  to  force  out  the  coccyx,  peel- 
ing off  at  the  same  time  the  fibrous  coveriug  of  its  anterior 
surface. 

If  the  sacrum  is  also  diseased,  and  the  gouge  is  used  upon 
it,  it  must  be  remembered  that  the  sacral  canal  extends  to 
its  very  end,  and  is  there  formed  posteriorly  not  of  bone, 
but  of  fibrous  tissue. 


RESECTION    OF    THE   SHAFT    OF    THE    FEMUR. 

A  longitudinal  incision  is  made  on  the  outer  side  in  the 
groove  betweeen  the  vastus  externus  and  biceps,  with  a 
transverse  liberating  incision  at  each  end.  Denudation  is 
carried  as  far  around  as  possible,  the  chain-saw  passed  at 
each  end  of  the  diseased  portion,  and  the  denudation  com- 
pleted as  the  piece  is  raised  from  its  bed. 

In  the  case  of  a  child  extension  should  be  made,  and  the 
limb  kept  at  the  same  length  as  the  other;  in  the  case  of. 

9* 


190  OPERATIVE  SURGERY. 

an  adult  the  fragments  should  be  brought  nearer  together 
as  the  patient  is  older,  aud  his  power  of  regeneration  less ; 
and,  in  many  cases,  it  is  better  to  bring  the  fragments  into 
contact.  Shortening  is  less  of  an  infirmity  than  pseudar- 
throsis. 


RESECTION    OF   THE   SHAFT    OF    THE    TIBIA. 

If  the  entire  diaphysis  of  the  tibia  become  necrotic  it 
may  be  removed  subperiosteally  and  a  fairly  useful  limb 
obtained,  especially  iu  children.  The  incision  is  made  par- 
allel to  aud  just  in  front  of  the  internal  border.  At  the 
upper  end  it  lies  behind  the  tendons  of  the  sartorius,  gra- 
cilis, and  semitendinosus ;  further  down  the  internal  saph- 
enous nerve  is  recognized  aud  drawn  to  one  side. 

The  periosteum  is  incised  on  this  line,  and  raised  with  au 
elevator  which  should  be  well  curved  to  get  around  the 
sharp  angles  of  the  bone.  When  the  denudation  has  been 
completed,  if  the  bone  is  not  already  detached,  the  elevator 
is  used  to  press  back  aud  protect  the  soft  parts  behind,  while 
the  bone  is  chiselled  or  sawn  through  as  close  to  the  dead 
area  as  possible.  A  transverse  incision  through  the  perios- 
teum at  this  point  will  save  undesirable  denudation  of  ad- 
joining healthy  bone. 

The  operation  is  most  frequently  required  to  remove  the 
necrosed  fragments  which  may  result  from  a  compound 
fracture  or  an  osteomyelitis. 

It  is  wise  to  delay  interference  till  separation  of  the  frag- 
ment has  occurred,  aud  then  the  location  of  the  incision 
will  depend  largely  on  the  position  of  the  sinuses.  Iu  gen- 
eral it  should  extend  between  the  two  which  are  most  widely 
separated ;  or,  if  there  is  only  a  single  sinus,  the  centre  of 
the  incision  should  correspond  to  this.  It  is  made  in  the 
long  axis  of  the  limb  as  already  described,  aud  the  perios- 
teum elevated. 

If  there  is  an  involucrum,  it  must  be  chiselled  away  very 
freely  on  each  side  of  the  central  cavity,  so  as  practically  to 
abolish  the  latter,  and  the  sound  bone  at  each  end  of  this 
cavity  must  be  freely  cut  away,  so  as  to  leave  a  surface 
sloping  easily  down  to  the  bottom  (posterior  wall)  of  the 


EXCISION  OF  JOINTS  AND  BONES.  191 

cavity.  The  object  of  this  free  removal  of  bone  is  to  per- 
mit the  soft  parts  to  come  everywhere  into  contact  with  the 
bone  when  they  are  brought  back  and  sutured  together  over 
it.  No  anxiety  as  to  subsequent  weakness  of  the  bone  need 
be  felt,  for  the  new  formation  of  bone  will  be  ample. 

If  it  is  necessary  to  reach  the  tibia  on  its  external  surface 
the  skin  iucision  should  lie  a  little  to  the  outer  side  of  the 
crest.  The  periosteum  is  cut  into  close  to  the  anterior  bor- 
der of  the  bone,  aud  elevated  with  the  attached  tibialis 
anticus  muscle.  When  the  gap  after  a  compound  fracture 
involves  the  entire  thickness  of  a  portion  of  the  shaft,  a  cor- 
responding length  must  be  removed  from  the  shaft  of  the 
fibula  to  secure  good  apposition  of  the  parts.  The  fibula  is 
best  approached  at  some  distance  above  or  below  the  site 
of  the  tibial  injury,  as  thus  there  will  be  less  danger  of 
infecting  this  fresh  wound,  and  subsequent  immobility  can 
be  more  readily  secured. 

The  posterior  surface  of  the  tibia  is  best  approached 
around  its  internal  border.  At  the  upper  extremity  the 
incision  is  made  as  already  described  behind  the  sartorius, 
gracilis,  and  semitendinosus,  and  the  periosteum  elevated 
with  the  attached  popliteus  muscle. 


RESECTION   OF   THE   FIBULA. 

The  lower  portion  of  the  fibula  is  subcutaneous,  its  upper 
portion  is  covered  by  the  peroneal  muscles.  The  biceps  is 
attached  to  its  head,  and  the  external  popliteal  or  peroneal 
nerve,  after  following  the  posterior  border  of  the  tendon  of 
that  muscle,  winds  around  the  outer  side  of  the  neck  of  the 
fibula,  and  divides  into  the  anterior  tibial  and  musculo- 
cutaneous, the  latter  of  which  soon  becomes  superficial. 
Sometimes  this  division,  and  even  the  subsequent  ones,  take 
place  as  high  up  as  the  head  of  the  fibula,  and  then  there 
is  danger  of  dividing  some  of  the  branches  during  resection 
of  the  upper  extremity  of  the  bone,  unless  the  method  indi- 
cated by  Oilier  is  strictly  carried  out.  The  earlier  authors 
considered  the  division  of  this  nerve  unavoidable. 

As  the  upper  tibio-fibular  articulation  communicates  in  a 
large  proportion  of  cases  with  that  of  the  knee,  it  should 


192  0PERA1IVE  SURGERY. 

not  be  opened,  except  when  it  shares  in  the  disease.  The 
head  of  the  fibula  should  be  divided  or  gouged  out  in  such 
a  way  as  to  leave  this  articulation  covered  by  a  thin  but 
complete  plate  of  bone. 

Resection  of  the  Upper  Extremity  of  the  Fibula  (Oilier).1 
A  longitudinal  incision  is  begun  an  inch  above  the  head  of 
the  fibula  at  the  posterior  border  of  the  tendon  of  the  bi- 
ceps, and  carried  down  a  little  behind  the  bone  along  the 
interstice  between  the  soleus  and  the  peroneal  muscles. 
The  incision  should  involve  only  the  skin  and  fascia. 

The  nerve  is  then  sought  for  where  it  passes  around  the 
neck  of  the  fibula,  and  protected  by  two  blunt  hooks  placed 
about  an  inch  apart.  While  thus  protected,  it  is  freed 
from  the  cellular  tissue,  which  binds  it  to  the  bone,  and 
then  drawn  forward  so  as  to  permit  the  division  of  the 
periosteum.  This  division  is  made  on  the  posterior  border 
of  the  bone,  and  carried  downward  as  far  as  is  necessary  in 
the  interstice  between  the  soleus  and  peroneal  muscles. 

The  periosteum  is  then  detached  and  the  bone  removed, 
either  by  dividing  it  at  two  points  with  a  chain-saw  or 
chisel  and  removing  the  intermediate  portion,  or  by  di- 
viding it  at  the  lower  limit  of  the  disease,  and  twisting  out 
the  upper  fragment,  or  by  modifying  the  latter  method  to 
the  extent  of  dividing  the  head  of  the  bone  with  a  sharp 
chisel  in  such  a  manner  as  to  leave  the  tibio-fibular  ioint 
unopened. 

Resection  of  the  Lower  Portion  of  the  Fibula.  Longi- 
tudinal incision  along  the  antero-external  aspect  of  the  bone. 
Denudation  and  removal  of  the  bone  in  the  usual  manner. 
For  other  details,  see  excision  of  the  ankle-joint. 


EXCISION    OP   THE   WHOLE    FIBULA. 

As  the  incisions  for  the  resection  of  the  upper  and  lower 
portions  lie  on  opposite  sides  of  the  peroneal  muscles,  they 
cannot  be  made  continuous  with  eaeh  other.  Each  half  of 
the  bone  must  be  removed  separately. 

1  Trait6  do  la  Iteg6u6ration  des  Os,  p.  207. 


EXCISION  OF  JOINTS  AND  BONES.  193 


EXCISION   OF   THE    BONES    OF   THE    FOOT. 

Calcaneum.  Disease  of  the  tarsal  bones  is  apt  to  origi- 
nate in  the  calcaneo-astragaloid  articulation  and  then  in- 
volve the  calcaneum  mainly,  the  astragalus  being  only 
superficially  affected.  The  disease  in  the  former  is  usually 
central,  leaving  a  sequestrum  inclosed  in  a  shell  of  rarefied 
vascular  bone,  or  a  cavity  is  formed  within  a  similar  shell 
by  ulceration  and  discharge  through  one  or  more  fistula?. 
The  removal  of  the  entire  thickness  of  the  bone  gives  better 
results  than  simple  gouging  out  of  the  diseased  portions, 
evidement  de  I'os,  but  the  anterior  portion  should  if  possible 
be  left,  as  it  favors  reproduction  of  the  bone. 

The  English  surgeons  do  not  usually  employ  the  sub- 
periosteal method,  claiming1  that  the  results  obtained  by 
the  ordinary  method  are  so  good  that  they  are  disinclined 
to  make  any  change.  So  far  as  can  be  judged  from  the 
published  descriptions,  these  results,  although  satisfactory  so 
far  as  the  restoration  of  function  is  concerned,  are  inferior 
to  those  obtained  by  the  superiosteal  method.  The  absence 
of  the  calcaneum  destroys  the  plantar  arch  and  the  sightli- 
ness if  not  the  usefulness  of  the  foot,  whereas  in  some  of 
Ollier's  superiosteal  cases  the  new  heel  was  as  prominent 
and  firm  as  that  of  the  other  foot. 

A.  Holmes's  Method.  An  incision  is  commenced  at  the 
inner  edge  of  the  tendo  Achillis,  and  drawn  horizontally 
forward  along  the  outer  side  of  the  foot  to  a  point  some- 
what in  front  of  the  calcaneo-cuboid  articulation.  This 
incision  should  go  down  at  once  upon  the  bone,  so  that  the 
tendon  should  be  felt  to  snap  as  the  incision  is  commenced. 
It  should  be  on  a  level  with  the  upper  border  of  the  os 
calcis.  Another  incision  is  then  made  vertically  across  the 
sole,  commencing  near  the  anterior  end  of  the  former  inci- 
sion and  ending  at  the  outer  border  of  the  internal  surface 
of  the  os  calcis.  The  bone  being  now  denuded  by  throwing 
back  the  flaps,  the  calcaneo-cuboid  and  calcaneo-astragaloid 
joints  are  sought  for  and  laid  open.  The  calcaneum  having 
been  thus  separated  from  its  bony  connections  by  the  free 

1  Holmes :  System  of  Surgery,  vol.  v.  p.  720. 


194 


OPERATIVE  SURGERY. 


Fig.  76. 


use  of  the  knife,  aided,  if  necessary,  by  the  lever,  lion- 
forceps,  etc.,  the  soft  parts  are  next  to  be  cleaned  off  its 
inner  side  with  care,  in  order  to  avoid  the  vessels,  and  the 
bone  will  then  come  away. 

B.  Subperiosteal  Method  (Oilier.)  Fig.  76,  A.  An  in- 
cision involving  only  the  skin  is  begun  at  the  outer  border 

of  the  tendo  Achillis  about  an 
inch  higher  than  the  tip  of  the 
external  malleolus,  carried  down 
below  the  outer  tuberosity  of 
the  calcaneum  and  then  forward 
and  slightly  upward  to  the  up- 
per part  of  the  base  of  the  fifth 
metatarsal.  The  edge  of  the  ten- 
do  Achillis  and  the  upper  border 
of  the  plantar  muscles  being- 
recognized,  the  incision  is  car- 
ried down  to  the  bone,  care  being 
taken  not  to  cut  the  peroneal 
tendons. 

The  posterior  half  of  the  bone 
is  then  denuded  with  an  ele- 
vator,   and    the   tendo    Achillis 

a.  Excision  of  the  calcaneum.  detached  and  pressed  to  the  inner 

b.  Excision  of  the  astragalus,    side.      The    under    surface   and 

posterior  third  of  the  inner  sur- 
face are  next  cleared,  the  peroneal  tendons  drawn  aside 
with  blunt  hooks,  the  external  lateral  ligament  detached, 
the  anterior  portion  of  the  outer  surface  denuded,  and  the 
calcaneocuboid  joint  opened. 

The  interosseous  ligament  is  divided  with  a  narrow  bis- 
toury, the  bone  grasped  with  lion-forceps  and  turned  down- 
ward so  as  to  open  the  calcaneo-astragaloid  joints  and  give 
access  to  the  calcaneo-scaphoid  and  internal  lateral  liga- 
ments and  to  the  inner  surface  of  the  bone. 

It  is  difficult,  if  not  impossible;  to  avoid  opening  some  of 
the  tendinous  sheaths  during  the  operation,  but  the  damage 
is  very  much  less  than  that  inflicted  by  the  former  method. 

I  {cscction  of  the  posterior  portion  alone  can  be  accom- 
plished much  more  expeditiously.  The  portion  to  be  re- 
moved is  denuded  and  then  sawn  off,  either  directly  or  by 


EXCISION  OF  JOINTS  AND  BONES. 


195 


perforating  the  bone  and  sawing  it  from  above  downward 
with  a  chain-saw. 

C.  Farabeufs    Method.      (Fig.  77,   C.)      The   incision 
begins  opposite  the  base  of  the  fifth  metatarsal  bone  exter- 


FlG.  77. 


A.  Excision  of  astragalus.    (Vogtv 

B.  Excision  of  ankle. 

C.  Excision  of  calcis.    (Farabeuf.) 


nally,  and  is  carried  horizontally  backward  just  above  the 
margin  of  the  sole.  It  passes  on  the  same  level  around  the 
back  of  the  heel  and  is  prolonged  forward  about  an  inch 
on  its  internal  aspect.  A  second  incision  extends  from  this 
about  two  inches  vertically  upward  beside  the  external 
border  of  the  tendo  Achillis.  These  incisions  involve  the 
skin  only.  The  vertical  cut  is  now  deepened  and  the  peri- 
osteum divided  in  this  line,  taking  care  not  to  damage  the 
peroneal  tendons  which  lie  just  anteriorly.  The  periosteum 
with  the  associated  ligaments  is  elevated  first  on  the  outer 
surface,  aided  by  deepening  the  horizontal  incision  in  this 
part  down  to  the  bone.  The  attachment  of  the  tendo 
Achillis  is  cut  and  the  posterior  aspect  cleared  as  far  as  pos- 
sible. 

The  periosteum  of  the  anterior  end  is  next  separated 
together  with  its  attached  ligaments,  and  afterward  the 
plantar  area  is  denuded.  The  anterior  extremity  is  grasped 
with  forceps  and  twisted  outward,  while  the  remaining 
attachments  are  severed  with  the   knife,  which  must  be 


196  OPERATIVE  SUBGEBT. 

kept  close  to  the  bone.  The  superior  surface  is  reached 
through  the  outer  incisiou  and  the  interosseus  ligament 
cut.  By  careful  work  with  the  elevator  the  internal  sur- 
face is  freed  from  the  periosteum  and  attached  ligaments 
aud  the  boue  finally  removed  without  damage  to  the  vessels 
and  nerves  on  its  inuer  side. 

Astragalus.  Excision  of  the  astragalus  may  be  rend- 
ered necessary  by  dislocation,  comminuted  fracture,  or 
caries,  or  it  may  be  made  as  a  preliminary  step  in  excision 
of  the  ankle.  Oilier  considers  this  operation,  under  nor- 
mal circumstances,  the  most  difficult  of  all  excisions.  He 
employs  the  following  method  on  the  cadaver : 

Operation  (Oilier).  Fig.  76,  B. — Curved  incision  across 
the  dorsum  of  the  foot,  with  convexity  directed  forward, 
beginning  on  the  inner  side  at  the  point  where  the  tendon 
of  the  tibialis  anticus  crosses  the  tibio-tarsal  articula- 
tion, running  forward  and  outward  to  the  middle  of  the 
scaphoid,  and  then  backward  to  a  point  a  little  below  the 
tip  of  the  external  malleolus.  This  incision  must  expose 
but  not  involve  the  tendons. 

The  extensor  tendons  are  lifted  out  of  their  sheaths  aud 
drawn  aside,  the  extensor  brevis  cut  across  or  detached  at  its 
origin,  and  the  neck  and  outer  non-articular  surface  of  the 
astragalus  cleared.  The  capsular  and  ligamentary  attach- 
ments of  the  bone  to  the  scaphoid  and  tibia  are  separated, 
the  interosseous  ligament  divided,  and  the  foot  being 
turned  inward  the  insertion  of  the  strong  internal  tibio- 
astragaloid  ligament  is  detached.  The  remaining  connec- 
tions are  then  ruptured  by  grasping  the  bone  with  strong 
forceps  and  twisting  it  out. 

Verneuil  thinks  the  operation  is  made  easier  by  saw- 
ing through  the  neck  of  the  boue  and  first  removing  the 
head. 

See  also  Vogt's  (Fig.  77)  excision  of  the  ankle,  p.  195. 

When  dislocated  the  astragalus  may  be  easily  removed 
by  a  straight,  curved,  or  crucial  incision  made  over  the 
most  prominent  part,  and  avoiding  vessels,  nerves,  aud 
tendons. 

When  badly  shattered,  as  in  gunshot  injury,  the  fragments 
may  be  removed  through  a  longitudinal  incision  between  the 
extensor  tendons  of  the  first  and  second  toes. 


EXCISION  OF  JOINTS  AND  BONES.  197 

For  simultaneous  removal  of  the  calcaneum  and  astraga- 
lus see  Osteoplastic  excision  of  the  foot,  p.  159. 

Metatarsal  Bones  and  Phalanges.  A  metatarsal  bone 
should  be  exposed  by  an  incision  along  the  dorsum  involv- 
ing only  the  skin  ;  the  tendon  is  then  drawn  aside,  the 
periosteum  divided,  the  bone  denuded,  sawn  through,  and 
removed.  Whenever  possible,  the  upper  extremity  of  the 
bone  should  be  left. 

For  the  first  and  fifth  metatarsals  it  is  better  to  make  the 
incision  more  upon  the  side  than  upon  the  dorsum. 

If  the  corresponding  toe  is  to  be  preserved,  extension 
must  be  made  upon  it  for  a  long  time,  in  the  manner  and 
for  the  reasons  mentioned  under  excision  of  the  metacarpal 
bones. 

The  phalanges  and  their  articulations  are  best  excised  by 
lateral  incisions. 

TREPHINING. 

Trephining  of  the  Cranium  may  be  undertaken  for  the 
evacuation  of  an  intra-cranial  abscess  or  hemorrhagic  effu- 
sion, or  for  the  removal  of  a  suspected  tumor  of  the  brain 
or  meninges,  or  for  the  cure  of  epilepsy,  or  after  fracture 
to  raise  depressed  portions  of  the  bone.  In  all  except  the 
latter  case  the  advisability  of  the  operation  may  be 
diminished  by  the  difficulty  of  determining  the  point  at 
which  the  trephine  should  be  applied.  Among  the  more  or 
less  trustworthy  indications,  according  to  which  the  surgeon 
must  make  his  selections  of  this  point,  may  be  mentioned  : 
the  history  of  an  injury  more  or  less  recent,1  with  or  without 
pain  and  inflammation  of  the  soft  parts  (Pott's  puffy  tumor) 
at  the  point  where  the  injury  was  received  ;  constant,  well 
localized  pain  at  any  one  point;  injury  over  the  course  of 
one  of  the  larger  meningeal  arteries  with  rapidly  super- 
vening symptoms  of  compression,  functional  disturbance 
of  certain  groups  of  motor  nerves. 

The  results  obtained  by  certain  physiologists  in  their 
efforts  to  determine  the  location  of  motor  centres  in  the  cor- 
tex of  the  brain  have  inspired  the  hope  that  the  injured  or 

1  In  a  case  of  Dupuytren's  there  was  no  sign  of  the  abscess  until  ten  years  after 
the  receipt  of  the  injury. 


198 


OPERATIVE  SURGERY. 


compressed  portion  of  the  brain  might  be  localized  exactly 
in  any  given  case  by  consideration  of  the  muscles  or  groups 
of  muscles  paralyzed.     This  hope  has  been  in  part  realized 
and  surgical  interference  has  been  successfully  based  upon 
paralytic  symptoms  in  fracture  of  the  cranium,  abscess  of 
the  brain,  tumor  of  the  brain, intra-cranial  hemorrhage,  etc. 
To  secure  success  in  the  operative  surgery  of  the  brain, 
the  most  scrupulous  asepsis  must  be  observed.     The  head 
is  to  be  entirely  shaved  twenty -four  hours  before  operation, 
aud  cleaned,  and  the  fissures  of  Rolando  and  Sylvius  and 
any  other  desired  landmarks  painted  on 
the  skin  with   iodine.     After  the  ad- 
ministration of  the  anaesthetic,  and  be- 
fore  any   incision    is   made,   the  scalp 
should  be  punctured  with  an  awl  or 
some  sharp  instrument  to  mark  upon 
the  skull  the  position  of  the  guiding- 
line  and  the  exact  spot  for  the  applica- 
tion of  the  trephine  point.     This  is  for 
reference  after  the  skin  has  been  divided 
and  retracted. 
Trephine.  The  incision  is  horseshoe  shaped,  with 

base  downward,  in  order  to  secure  the 
best  nutrition  for  the  flap,  and  so  situated  that  it  can  be 
enlarged  if  found  necessary  later  on.  It  should  be  made 
three-fourths  of  its  expected  length  with  one  sweep  of  the 
knife.  After  the  vessels  have  been  tied  it  is  enlarged  to 
its  intended  size.  The  pericranium  is  not  dissected  up 
with  the  skin  flap,  but  is  afterward  elevated  from  the  area 
of  bone  to  be  removed.  In  general  the  trephine  hole  should 
be  at  least  one  and  a  half  inches  in  diameter,  and  if  more 
room  is  needed  it  can  be  enlarged  by  the  rongeur,  or  two 
trephine  holes  can  be  made  and  the  intervening  bone  chis- 
elled or  sawn  away.  If  Horsley's  electric  saw  is  used  a 
thin,  flat  steel  instrument  must  be  kept  beneath  it  between 
the  bone  and  the  dura  to  protect  the  latter. 

The  centre-pin  of  (he  trephine  having  been  protruded 
one-sixteenth  of  an  inch  and  fastened  in  its  place  by  the 
binding  screw  on  the  side,  it  is  forced  by  to-and-fro 
rotatory  movements  upon  its  point  into  the  bone  at  the 
place  selected,  and  these  movements  continued  until  the 


EXCISION  OF  JOINTS  AND  BONES.  199 

circular  edge  of  the  trephine  has  cut  a  groove  sufficiently 
deep  to  iusure  its  steadiness  without  the  aid  of  the  pin,  which 
must  then  be  withdrawn,  so  as  to  avoid  injury  by  it  to  the 
dura  mater.  The  rotatory  movements  are  continued  very 
cautiously,  and  all  parts  of  the  groove  frequently  examined 
with  a  probe,  as  its  depth  increases,  so  as  to  have  timely 
notice  of  complete  perforation. 

The  teeth  of  the  trephine  must  be  freed  from  dust  from 
time  to  time  by  means  of  a  brush  or  by  dipping  the  instru- 
ment into  sterilized  water.  If,  as  is  usually  the  case,  per- 
foration takes  place  upon  one  side  of  the  groove  before  it 
does  upon  the  other,  the  trephine  must  be  slightly  inclined 
so  as  to  act  only  upon  the  unsawn  portion ;  or  a  thin- 
bladed  elevator  may  be  used  to  lift  or  pry  out  the  disk, 
breaking  the  thin  shell  which  remains. 

It  is  possible  to  replace  even  large  plates  of  bones  and 
secure  bony  union,  although  the  attempt  more  often  fails. 
If  this  is  to  be  attempted,  wrap  the  fragment  removed  in 
a  towel  dampened  with  a  1  to  2000  solution  of  bichloride 
of  mercury,  or  immerse  it  in  a  plain  sterilized  salt  solu- 
tion, and  in  either  case  keep  it  at  the  temperature  of  99°  F. 

Hemorrhage  from  the  diploe  is  checked  by  simple  sponge 
pressure  or  by  plugging  the  larger  vessels  with  decalcified 
bone,  softened  catgut,  a  piece  of  aseptic  sponge,  or  Hors- 
ley's  wax.  This  is  made  of  wax  7  parts,  oil  2  parts,  car- 
bolic acid  1  part.  The  dura  mater  is  cut  one-quarter  of 
an  inch  from  the  bony  margin,  and  the  incision  should  have 
a  horseshoe  shape.  It  is  lifted  carefully  to  avoid  injury  to 
the  vessels  of  the  pia,  as  the  hemorrhage  from  these  may 
be  profuse  and  troublesome.  Any  arteries  on  the  dura  are 
ligated  before  their  division  by  passing  a  small  curved 
needle. 

Hemorrhage  from  the  pia  or  brain  is  checked  by  sponge 
or  gauze  pressure.  If  these  fail  the  vessels  are  clamped 
and  tied  with  fine  catgut  ligatures.  The  Paquelin  cautery 
may  be  used  as  a  last  resort.  The  brain  can  be  punctured 
cautiously  with  a  probe  or  hypodermic  needle,  but  all  lat- 
eral movements  should  be  avoided.  CEdema  of  the  pia  is 
evacuated  by  a  few  small  incisions  aided  by  the  pressure  of 
a  sponge. 

If  the  brain  has  to  be  incised  pass  the  knife  through  the 


200  OPERATIVE  SURGERY. 

summit  of  a  convolution,  as  the  hemorrhage  is  less  than 
when  the  incision  is  made  at  the  bottom  of  a  sulcus.  A 
clot  can  be  wiped  out  with  fine  sponges  or  picked  out  with 
forceps.  An  encapsulated  tumor  is  enucleated  with  curved 
blunt-pointed  scissors,  aided  by  the  finger.  But  one  that 
infiltrates  the  brain  must  be  cut  out  with  the  knife.  The 
use  of  the  sharp  spoon  is  not  allowable  in  this  situation. 

A  superficial  cyst  is  either  enucleated,  or,  after  cutting 
off  its  superficial  surface,  it  is  simply  packed  and  drained. 
A  deeper  cyst  is  evacuated  and  packed  or  continuous  drain- 
age maintained  by  a  strip  of  rubber  tissue.  A  cavity  re- 
maining after  the  removal  of  a  cyst  or  tumor  is  packed 
with  gauze,  which  is  removed  gradually  to  prevent  the 
space  filling  with  a  blood  clot.  A  clot  may  be  allowed  to 
form  if  there  is  perfect  confidence  that  asepsis  has  been 
maintained.  If  bulging  of  the  brain  occurs  the  protrud- 
ing part  should  be  held  back  by  a  thin  spatula,  which  is 
gradually  withdrawn  as  the  dural  incision  is  closed  over  it 
by  a  continuous  catgut  suture.  If  it  is  impossible  thus  to 
hold  the  brain  back  the  protruding  part  may  be  sliced 
away  or  wiped  off  with  a  sponge.  True  hernia  cerebri 
after  an  operation  is  rare  when  perfect  asepsis  has  been 
maintained. 

Any  alarming  hemorrhage  from  a  sinus  or  large  vein  can 
usually  be  checked  by  gauze  pressure;  if  this  fail  artery 
clamps  can  be  applied  and  left  in  the  dressings  for  several 
days.  A  bleeding  sinus  has  been  sutured  successfully,  but 
it  is  difficult.  At  the  close  of  the  operation  a  folded  strip 
of  rubber  tissue  is  passed  as  a  drain  beneath  the  dura, 
which  is  stitched  with  catgut  except  at  this  point,  and 
brought  out  of  the  lower  angle  of  the  skin  wound.  Often 
the  drain  is  unnecesary,  and  the  wounds  in  the  dura  and 
skin  may  be  closed  up  tight,  the  former  with  catgut,  the 
latter  with  silk,  and  dressed  aseptically. 

Temporary  Resection  of  the  Skull  by  Omega  Flap.  The 
incision  takes  the  form  of  a  Greek  SJ,  with  base  downward 
to  secure  the  best  nutrition  to  the  flap.  Everything  is 
divided  down  to  the  pericranium.  The  horizontal  feet  of 
the  loop  are  each  about  half  an  inch  long  and  separated 
from  each  other  across  the  base  by  at  least  an  inch  of  sound 
skin.     The  size  of  this  pedicle  varies  with  that  of  the  flap, 


EXCISION  OF  JOINTS  AND  BONES.  201 

its  width  being  a  good  half  of  that  of  the  latter.  The 
horizontal  cuts  serve  as  liberating  incisions  to  facilitate  the 
turning  down  of  the  flap  with  its  attached  bone.  The 
dimensions  of  the  loop  can  of  course  be  made  to  vary  to 
suit  the  requirements  of  each  case,  but  as  used  by  Wagner.1 
They  are  follows :  Vertical  length,  6.5  cm. ;  greatest  breadth, 
5  cm.;  with  a  pedicle  of  undivided  sound  tissue,  3  cm.  wide. 

After  the  soft  parts  have  retracted  the  periosteum  is  cut 
close  up  and  parallel  to  the  inner  edge  of  the  skin  in  the 
loop  and  its  horizontal  continuations  below,  and  the  bone 
chiselled  through  along  the  entire  curved  portion.  A  perios- 
teal elevator  is  cautiously  pushed  in  as  a  lever  at  the  top 
of  the  curve  and  the  bone  flap  snapped  at  its  base  by  a 
sudden  quick  application  of  force  and  laid  back  without 
disturbing  the  attached  parts.  It  may  be  necessary  to  aid 
this  breaking  by  chiselling  of  the  outer  table  from  either  or 
both  angles  part  way  across  the  bone.  The  dura  is  opened 
as  described  in  the  operation  of  trephining.  When  the 
bone  fragment  is  replaced  it  is  held  in  position  and  pre- 
vented from  pressing  unduly  upon  the  dura  by  the  project- 
ing spicules  of  the  vitreous  plate  formed  by  the  fracture. 
The  skin  flap  overlaps  the  line  of  bony  division  about  one- 
quarter  to  one-half  an  inch,  and  is  united  by  interrupted 
silk  sutures,  with  or  without  drainage  in  the  lower  angle  of 
the  wound.  By  this  method  it  is  claimed  the  bone  can  be 
replaced  with  less  danger  of  necrosis  than  when  it  has  been 
entirely  separated  from  its  sources  of  nutrition,  and  if  it 
does  necrose  it  is  just  as  easy  to  remove  as  in  the  cases 
where  the  bone  has  been  replaced  after  an  ordinary  trephin- 
ing- 

This  is  the  description  of  the  operation  as  given  by  its 
originator,  but  practically  the  horizontal  "  feet "  of  the  Q 
may  generally  be  dispensed  with.  Their  only  use  is  in 
liberating  skin  incisions  to  facilitate  the  turning  down  of 
the  flap.  If  needed  they  can  be  made  after  the  section  of 
the  bone. 

To  chisel  through  the  skull,  two  gouges,  one  larger  than 
the  other,  will  be  found  most  useful.  The  outer  table  is 
divided  with  the  larger  instrument,  the  inner  table  with  the 
smaller  one  along  the  groove  made  by  the  first. 

1  Centralblatt  f.  Chir.,  1889,  p.  833. 


202  OPERATIVE  SURGERY. 

Oranieciomy  (Lannelongue).  An  incision  parallel  to  and 
a  finger-breadth  to  one  side  of  the  longitudinal  sinus  is 
made  from  the  lambdoid  to  the  coronal  suture.  The  perios- 
teum is  elevated  in  this  line,  and  at  one  extremity  of  it  the 
skull  is  perforated  with  a  half-inch  trephine.  Then  with 
the  rongeur  or  chisel  a  strip  of  bone  from  a  quarter  to  half 
an  inch  wide  and  from  four  to  six  inches  long,  parallel  to 
the  sagittal  suture  and  about  an  inch  distant  from  it,  is  ex- 
sected.  This  has  sometimes  been  extended  to  reach  from 
the  frontal  eminence  nearly  to  the  transverse  sinus. 

A  similar  strip  of  bone  has  occasionally  been  removed  at 
the  same  time  from  the  opposite  side  of  the  head,  and 
Lannelongue  has  performed  the  operation  in  the  transverse 
diameter  of  the  skull,  the  incision  and  exsected  bone  cor- 
responding nearly  to  the  coronal  suture.  A  flap,  concavity 
downward,  is  sometimes  fashioned  so  as  to  prevent  the  lines 
of  skin  and  bone  division  from  coinciding. 

Trephining  for  Fracture  of  the  Skull.  The  scalp  is 
shaved  and  cleaned  over  all  the  surrounding  area.  If  a 
wound  already  exists  it  is  enlarged ;  if  not,  a  semilunar 
incision  is  made  and  placed  with  due  regard  to  the  arteries 
leading  into  the  flap.  The  periosteum  is  divided  and  de- 
tached and  the  fracture  examined.  It  is  generally  possible 
after  removing  loose  fragments  with  dressing  forceps  to 
introduce  an  elevator  and  pry  up  the  depressed  portion, 
using  of  course  only  the  sound  part  of  the  skull  as  a  ful- 
crum. If  some  projecting  fragment  of  bone  prevent  this 
it  may  be  chiselled  away  enough  to  admit  of  lifting  or 
prying  up  the  depressed  part.  When  the  trephine  is  used 
the  point  is  so  placed  on  the  sound  bone  that  about  one-third 
of  the  cutting  edge  only  overlaps  the  injured  area,  and  the 
rest  will  expose  any  widespreading  comminution  of  the 
inner  table.  If  there  is  reason  to  think  a  sinus  has  been 
wounded,  the  trephine  opening  should  be  planned  to  give 
ready  access  to  the  bleeding  point.  All  splinters  and  loose 
fragments  are  taken  out  with  care  to  strip  off  any  adherent 
dura  on  the  inner  surface;  but  depressed  fragments  still 
retaining  a  hold  on  sound  bone  are  simply.elevated  and 
left.  Wounds  of  the  dura  are  sutured  with  fine  catgut,  and 
hemorrhage  from  it  is  checked  by  gently  applied  pressure 


EXCISION  OF  JOINTS  AND  BONES. 


203 


or  ligature.  Bleeding  from  a  diploic  vein  is  stopped  by 
plugging  its  lumen  with  aseptic  sponge  or  catgut  or  by 
crowding  in  a  little  of  the  surrounding  bone  tissue.  After 
thoroughly  cleaning  all  parts  of  the  wound  and  removing 
every  hair  or  trace  of  dirt,  it  is  closed  with  interrupted  silk 
and  drained  at  the  most  dependent  angle. 


Fig.  79. 


B.  Fissure  of  Bichat.  e.  a,  p.  External  angular  process  of  frontal  bone.  Sy. 
a.  fis.  Ascending  limb  of  Sylvian  fissure.  +.  Parietal  eminence.  F.  G.  D.H.  E. 
Perpendiculars  to  base  line  locating  tbe  fissure  of  Rolando  (F.H.).  p.  o.  fis. 
Parietooccipital  fissure,  l.fr.f.  First  frontal  fissure.  2.  fr.f.  Second  frontal  fis- 
sure. asc.fr.  con.  Ascending  frontal  convolution,  i.par.f.  Intra-parietal  fissure, 
s.  m.  c.  Supra-marginal  convolution,  ang.  g.  Angular  gyrus.  1.  t.  s.  c.  First  tem- 
poro-sphenoidal  convolution.  2.  t.  s.  c.  Second  temporo-spbenoidal  convolution. 
3.  t.  s.  c.  Third  tempo ro-sphenoidal  convolution,  l.t.s.f.  First  temporo-spbe- 
noidal fissure.    2.  t.  s.f.  Second  temporo-sphenoidal  fissure.    (Starr). 


The  Relation  of  the  Brain  to  the  Overlying  Parts.  Reid's 
method.1  The  "base  line"  is  drawn  through  the  lowest 
part  of  the  infra-orbital  margin  and  the  centre  of  the  ex- 
ternal auditory  meatus. 

The  great  longitudinal  fissure  is  marked  by  a  line  run- 
ning in  the  middle  line  of  the  skull  from  the  glabella  to  the 
external  occipital  protuberance. 

1  Lancet,  September  27, 1884. 


204 


OPERATIVE  SURGERY. 


The  transverse  fissure,  or  the  fissure  of  Bichat,  by  one 
from  the  external  occipital  protuberance  through  the  audi- 
tory meati. 

The  Sylvian  fissure  starts  one  and  one-quarter  inches 
horizontally  behind  the  external  angular  process  of  the  fron- 
tal bone,  and  extends  to  a  point  three-quarters  of  an  inch 
below  the  most  prominent  part  of  the  parietal  eminence. 

The  ascending  line  of  this  fissure  starts  at  a  point  in  this 
line  two  inches  behind  the  external  angular  process,  and 
ascends  vertically  about  one  inch. 


Pig.  80. 


Showing  the  location  of  the  centres  on  the  cortex  of  the  brain.    (Starr.) 

Fissure  of  Rolando.  Draw  a  perpendicular  to  the  base 
line  starting  in  the  depression  in  front  of  the  external  audi- 
tory meatus,  and  another  perpendicular  to  the  base  line 
starting  from  the  posterior  border  of  the  mastoid  process  at 
its  root.  The  fissure  of  Rolando  is  indicated  by  a  line  drawn 
from  the  intersection  of  this  second  line  with  the  line  mark- 
ing the  great  longitudinal  fissure,  to  the  point  of  intersec- 
tion of  the  anterior  perpendicular  with  the  horizontal  limb 
of  the  fissure  of  Sylvius  already  laid  out.  A  simpler  way 
of  indicating  the  Kolandic  fissure  is  to  draw  a  line  three  and 


EXCISION  OF  JOINTS  AND  BONES.  205 

three-eighths  inches  long  at  an  augle  of  67°  with  the  sagit- 
tal meridian  of  the  head,  from  a  point  which  lies  back  of 
the  glabella  in  this  meridian  55.7  per  cent,  of  the  distance 
from  the  glabella  to  the  inion.  Cheyne's  method  of  measur- 
ing this  angle  is  to  halve  a  right  angle  by  doubling  a  square 
piece  of  paper  into  a  triangle,  and  then  halve  the  45°  thus 
obtained  by  folding  one  of  the  triangles.  By  unfolding 
the  crease  first  made,  leaving  the  last  unchanged,  there  re- 
sults the  sum  of  45°  and  22|°,  or  67J°,  which  is  near 
enough  for  all  practical  purposes.  The  line  three  and  three- 
eighths  inches  long  is  then  laid  off  at  this  angle  by  means 

Fig.  81 


Showing  the  position  of  the  cortical  centres  with  reference  to  the  Sylvian  and 
Rolandic  fissures  marked  on  the  surface  of  the  skull.    (Starr.) 

of  the  folded  bit  of  paper  from  a  spot  half  an  inch  behind 
the  mid-point  between  the  glabella  and  the  external  occipi- 
tal protuberances. 

The  parieto-occijntal  fissure.  The  horizontal  limb  of  the 
fissure  of  Sylvius  is  prolonged  to  meet  the  longitudinal 
fissure.  A  trephine  opening  over  the  inner  inch  of  this  line 
will  reveal  a  whole  or  part  of  the  parieto-occipital  fissure. 
It  varies  slightly  up  or  down  in  its  location. 

The  frontal  lobe  lies  between  the  lines  indicating  the 
fissures  of  Rolando  aud  Sylvius  and  the  longitudinal  fissure 
and  a  line  drawn  from  the  glabella  close  to  and  parallel  to 

10 


206  OPERATIVE  SURGERY. 

the  supra-orbital  arch  to  meet  the  prolongation  of  the  Syl- 
vian fissure. 

The  first  frontal  fissure  is  indicated  by  a  line  drawn  from 
the  supra-orbital  notch  parallel  to  the  longitudinal  fissure 
and  ending  three-quarters  of  an  inch  in  front  of  the  fissure 
of  Rolando. 

The  second  frontal  fissure  is  indicated  by  the  frontal  part 
of  the  temporal  ridge. 

The  ascending  frontal  convolution  occupies  a  space  three- 
quarters  of  an  inch  broad  in  front  of  the  fissure  of  Ro- 
lando. 

The  parietal  lobe  lies  between  the  fissure  of  Rolando,  the 
horizontal  limb  of  the  fissure  of  Sylvius,  the  longitudinal 
and  parieto-occipital  fissures. 

The  intra-parietal  fissure  begins  on  the  horizontal  limb 
of  the  Sylvian  fissure — more  correctly  a  little  above  it — 
one  inch  behind  its  junction  with  the  fissure  of  Rolando, 
and  passes  upward  three-quarters  of  an  inch  behind  the 
latter  for  the  first  third  of  its  length.  Then  it  arches 
backward  and  downward  and  passes  half  an  inch  to  the 
outer  side  of  the  outer  extremity  of  the  line  indicating  the 
parieto-occipital  fissure. 

The  ascending  parietal  convolution  lies  between  the  fissure 
of  Rolando  and  this  first  third  of  the  intra-parietal  fissure. 

The  inferior  parietal  lobule  lies  between  the  horizontal 
limb  of  the  Sylvian  fissure  and  the  intra-parietal  fissure. 

TJie  supra-marginal  convolution  occupies  the  anterior 
portion  of  this  space  in  the  most  prominent  part  of  the 
parietal  eminence. 

The  angular  gyrus  occupies  the  posterior  portion. 

The  temporo- sphenoidal  lobe  lies  between  the  Sylvian  fis- 
sure and  the  base  line,  and  is  limited  behind  by  a  line  join- 
ing the  termination  of  the  horizontal  limb  of  the  Sylvian 
fissure,  with  the  centre  of  the  line  from  the  external  occi- 
pital protuberance  to  the  posterior  border  of  the  root  of  the 
mastoid  process. 

The  first  temporo-sphenoidal  fissure  is  indicated  by  a  line 
parallel  to  and  one  inch  below  the  Sylvian  fissure. 

The  second  temporo-sphenoidal  fissure  by  a  line  three- 
quarters  of  an  inch  below  this. 


EXCISION  OF  JOINTS  AND  BONES. 


207 


Kocher's  Method.  Kocher  uses  a  specially  constructed 
instrument  of  pliable  steel  bands  to  mark  out  the  position 
on  the  shaved  scalp  of  the  different  parts  of  the  brain 
which  lie  beneath.  By  reference  to  the  figure  the  nature 
of  this  instrument  can  be  readily  understood.     An  ordinary 

Fig.  82. 


Kocher's  cranial  topography.    (All  the  points  on  the  sagittal  meridan,  D,  C,  E, 
X,  lie  further  back  than  indicated  in  this  figure. 


metal  tape  measure  can  be  made  to  answer  the  purpose. 
The  band  ADCEB  extends  from  the  glabella  along  the 
median  line  to  the  lowest  point  of  the  external  occipital 
protuberance. 

The  horizontal  baud  A  J  Q  V  B  is  placed  at  right  angles 
to  this  around  the  side  of  the  head  between  the  same  two 
points.  For  convenience  the  lines  thus  marked  out  are 
called  the  sagittal  and  horizontal  meridians  of  the  head. 

From  the  centre,  C,  of  the  sagittal  meridian  two  bands 
each  at  the  same  angle  of  60°  to  the  sagittal  meridian  pass 
downward  to  meet  the  horizontal  meridian  at  the  points  J 
and  V. 

The  sagittal  meridian  is  now  divided  into  thirds,  the  last 
of  which  begins  at  E ;  and  next  into  fourths,  the  last  of 


208  OPERATIVE  SURGERY. 

which  begins  at  F.  At  a  point  midway  between  E  and  F 
the  band  X  Y  Z  Q  passes  at  right  angles  to  the  sagittal 
meridian  to  join  the  horizontal  at  Q,  which  is  usually  about 
half  an  inch  behind  J.  This  oblique  band  X  J2  is  divided 
into  thirds  at  Y  and  Z.  C  J  and  C  V  are  also  divided 
into  thirds  at  G,  H,  S,  and  T.  The  horizontal  meridian 
marks  the  lower  border  of  the  cerebrum.  The  point  J 
lies  about  at  the  pterion  or  junction  of  the  frontal  parietal 
and  spheuoidal  bones,  and  marks  the  anterior  end  of  the 
Sylvian  fissure  at  the  spot  where  the  ascending  joins  the 
horizontal  limb.  It  also  indicates  the  point  of  contact  of 
the  frontal  and  temporal  lobes.  V  lies  over  the  boundary 
between  the  temporal  and  occipital  lobes,  and  is  one  centi- 
metre below  the  edge  separating  the  outer  and  uuder  sur- 
faces of  the  brain. 

C  indicates  the  uppermost  point  of  the  anterior  central 
convolution,  and  is  in  front  of  the  fissure  of  Rolando.  At 
G  the  anterior  central  convolution  meets  the  first  and  second 
frontal  convolutions,  and  at  II  the  second  and  third.  S 
lies  over  the  intra-parietal  fissure  just  above  the  supra- 
marginal  gyrus.  T  indicates  the  posterior  extremity  of 
the  first  temporo-sphenoidal  fissure  and  is  below  the  angu- 
lar gyrus.  X  is  over  the  apex  of  the  lambdoidal  suture 
and  at  the  point  of  meeting  of  the  parieto-occipital  and 
great  longitudinal  fissure.  Q  indicates  the  anterior  ex- 
tremity of  the  first  temporo-sphenoidal  fissure.  The  pos- 
terior end  of  the  first  third  of  the  sagittal  meridian,  D,  is 
at  the  bregma. 

A  trephine  opening  close  to  one  side  of  C  reaches  the 
centre  for  the  lower  extremity — the  thigh  and  leg  are  near 
the  middle  line,  the  foot  and  toes  slightly  posterior. 

Between  H  and  G  is  the  centre  for  the  upper  extremity, 
in  the  upper  part  and  in  front  of  the  fissure  of  Rolando 
the  shoulder  and  elbow,  and  in  the  ascending  parietal  con- 
volution a  little  lower  down  the  centre  for  the  wrist,  fingers, 
and  thumb. 

A  little  above  II  the  trephine  exposes  the  centre  for  the 
upper  face  muscles,  just  below  H  the  lower  face  muscles. 
A  finger-breadth  directly  above  il  lies  the  centre  govern- 
ing the  movements  of  the  larynx  and  pharynx. 


EXCISION  OF  JOINTS  AND  BONES.  209 

In  front  of  the  middle  of  the  line  H  J  is  the  centre, 
injury  to  which  produces  motor  aphasia. 

The  auditory  centre  lies  under  the  posterior  half  of  the 
line  Z  Q. 

The  centre  for  visual  aphasia  is  below  the  point  T,  and 
just  above  the  line  B  V  is  the  centre  for  psychical  vision 
or  psychical  blindness. 

C.  Winkler1  has  elaborated  another  system  of  cerebral 
topography,  and  Langdon2  still  another.  D'Antona's3 
method  is  simple  and  easily  applied,  but  as  Reid's  original 
scheme  and  its  modifications  are  most  generally  known 
and  used,  it  has  not  seemed  worth  while  to  do  more  than  call 
attention  to  these  few  of  the  numerous  others  which  have 
recently  been  devised. 


THE    POSITION    OF    THE    LATERAL   SINUS. 

According  to  Birmingham4  the  limit  of  the  up-and-down 
variation  of  the  position  of  the  lateral  sinus  is  determined 
thus  :  At  a  point  one  and  a  half  inches  behind  the  centre 
of  the  external  auditory  meatus  it  begins  to  arch  down- 
ward. Measure  this  distance  along  the  base  line.  Then, 
at  a  point  one  and  a  quarter  inches  above  the  base  line  at 
this  spot,  draw  a  line  slightly  convex  upward  to  a  point 
half  an  inch  above  the  external  occipital  protuberance. 
Take  another  point  half  an  inch  below  the  external  occipital 
protuberance  and  connect  it  with  the  point  on  the  base  line 
one  and  a  half  inches  behind  the  centre  of  the  meatus. 
Outside  of  these  limits  there  is  no  danger  of  opening  the 
lateral  sinus. 

In  its  average  location  it  c^iends  from  the  external 
occipital  protuberance,  gradually  rising  to  a  point  three- 
quarters  of  an  inch  above  Reid's  base  line.  The  highest 
point  is  reached  one  and  a  half  inches  behind  the  centre  of 
the  external  auditory  meatus.  From  here  with  a  gradual 
or  sharp  turn  it  runs  downward  and  forward  on  the  inner 

1  Nederlandsch.  Tijdschrift  voor  Geneeskunde,  1892,  p.  158. 

2  Cincin.  Med.  Journ.,  Aug  16,1894. 

3  Annals  Surg.,  Dec.  1892. 

4  Dub.  Journ.  Med.  Science,  1891,  p.  116. 


210 


OPERATIVE  SURGERY. 


surface  of  the  mastoid  portion  of  the  temporal  bone  imme- 
diately in  front  of  a  ridge,  which  on  the  outer  surface  of 
the  skull  sometimes  prolougs  the  posterior  margin  of  the 
mastoid  process  upward  and  backward  and  in  front  of  the 


Fig.  83. 


A.  External  occiptal  protuberance  and  lateral  sinus. 

77    |   Limit  of  up  and  down  variation  in  position  of  the  lateral  sinus. 

D.  Incision  for  exposure  of  the  Gasserian  ganglion. 

posterior  margin  of  the  process  itself.  Here  it  lies  about 
half  an  inch  behind  the  meatus.  At  the  level  of  one- 
quarter  or  one-sixth  inch  below  the  floor  of  the  meatus  it 
turns  into  the  base  of  the  skull. 


To  Open  the  Lateral  Sinus.  Incision  about  two  inches 
in  length,  starting  near  the  lower  end  of  the  mastoid  pro- 
cess, and  passing  upward  along  the  ridge  on  its  posterior 
margin.     The  periosteum  is  divided  and  elevated.     The 


EXCISION  OF  JOINTS  AND  BONES. 


211 


pin  of  a  three-quarter-inch  trephine  is  placed  at  a  point  one 
aud  one-quarter  inches  behind  the  centre  of  the  external 
auditory  meatus  on  a  level  with  its  upper  border.  Accord- 
ing to  Birmingham  this  will  always  open  up  the  sinus.  The 
opening  in  the  bone  may  be  enlarged  as  circumstances 
require. 


TREPHINING    FOR    CEREBRAL    ABSCESS    DUE    TO    SUPPU- 
RATIVE  DISEASE   OF   THE   MIDDLE   EAR. 

The  pus  in  these  cases  is  most  frequently  found  in  the 
temporo-sphenoidal  lobe — next  in  order  of  frequency  in 


Fig.  84. 


1.  Trephine  opening  to  enter  the  mastoid  antrum.  2.  Trephine  opening  for 
abscess  following  otitis  media.  3.  Trephine  opening  to  expose  the  cerebellum. 
4-5.  Trephine  opening  for  middle  meningeal  hemorrhage.  A.  Lateral  sinus.. 
JJ-C.  Limit  of  its  up-and-down  variation. 


212  OPERATIVE  SURGERY. 

the  cerebellum.  According  to  Barker1  the  abscess  gen- 
erally occupies  a  space  between  two  lines  drawn  perpendic- 
ular to  Reid's  base  line.  The  first  passes  through  the  centre 
of  the  meatus,  the  second  one  and  one-quarter  inches  behind 
this  (Fig.  84,  2.) 

A  semilunar  incision,  convexity  downward,  is  made  just 
above  and  behind  the  pinna.  The  periosteum  is  divided  and 
elevated  sufficiently  for  the  use  of  a  three-quarter-inch  tre- 
phine. The  pin  of  this  is  placed  one  and  one-quarter  inches 
above  the  base  line  in  the  centre  of  the  space  enclosed  by  the 
perpendiculars.  Birmingham2  shows  that  in  a  certain  pro- 
portion of  cases  a  trephine  thus  applied  will  come  down  on 
the  bend  of  the  lateral  sinus,  and  proposes  as  a  safer  location 
to  place  the  point  of  the  trephine  at  least  one  and  three- 
quarter  inches  above  the  base  line,  or,  better  still,  two 
inches. 

Keen  places  the  pin  of  the  trephine  an  inch  and  a  quarter 
behind  and  the  same  distance  above  the  external  auditory 
meatus. 

After  the  removal  of  the  button  of  bone  the  dura  is 
incised  with  the  knife,  and  the  opening  enlarged  in  the 
shape  of  a  crucial  incision  with  blunt-pointed  scissors.  The 
abscess  is  located  with  an  aspirating  needle,  and  an  opening 
large  enough  for  a  drainage  tube  is  made  with  some  blunt 
instrument. 

The  flaps  are  then  adjusted  and  partially  sutured  in  posi- 
tion, leaving  sufficient  room  for  the  escape  of  pus. 


TREPHINING   OF  THE   CEREBELLUM. 

A  transverse  incision  is  made  along  the  superior  curved 
line  of  the  occiput.  Everything  is  divided  down  to  the  bone. 
The  sterno-mastoid,  trapezius,  and  underlying  muscles 
are  raised  with  the  periosteum.  These  soft  parts  will  con- 
tain the  divided  occipitalis  minor  and  major  nerves  and  the 
occipital  artery.  The  skull  is  opened  below  the  superior 
curved  line  and  behind  the  masto-occipital  suture  by  placing 
the  pin  of  a  three-quarter-inch  trephine  one  incli  below 

>  British  Medical  Journal,  1887,  vol.  i.  p.  407. 
!  Dublin  Joum  Med.  Science,  lS'Jl,  p.  111). 


EXCISION  OF  JOINTS  AND  BONES.     .  213 

Reid's  base  line  at  a  point  two  inches  behind  the  centre  of 
the  external  auditory  meatus  measured  along  the  base  line 
(Fig.  84,  3). 

Barker  advises  one  and  one-half  inches  behind  the  centre 
of  the  meatus  and  one  inch  below  the  base  line,  but  Bir- 
mingham says  a  three-quarter-inch  trephine  would  wound 
the  occipital  artery  in  many  cases  in  this  situation. 


PUNCTURE  OF  THE  LATERAL  VENTRICLES  (kOCHER). 

An  inverted  U-shaped  incision  is  made  to  expose  the  skull 
at  T  (Fig.  80).  The  enclosed  flap  should  be  about  one  and 
one-half  inches  long  by  an  inch  wide.  After  turning  down 
the  skin  and  securing  the  vessels  the  periosteum  is  incised 
and  elevated,  and  the  point  of  the  trephine  entered  just 
below  and  in  front  of  T.  The  skull  is  thin  in  this  region. 
This  exposes  the  posterior  end  of  the  first  temporo-sphe- 
noidal  fissure.  The  posterior  horn  of  the  lateral  ventricle 
lies  about  1  cm.  distant  from  the  bottom  of  the  sulcus 
directly  inward. 

Another  method  of  locating  the  opening  to  be  made  in 
the  skull  (Keen)  is  to  measure  one  and  one-quarter  inches 
back  of  the  external  auditory  meatus  along  Reid's  base 
line  and  then  one  and  one-quarter  inches  vertically  upward. 
At  this  point  apply  the  pin  of  a  half-inch  trephine.  After 
incising  the  dura  push  a  grooved  director  or  trocar  in  a 
straight  line  toward  a  spot  about  two  and  one-half  or  three 
inches  above  the  opposite  meatus.  The  ventricle  will  nor- 
mally be  reached  at  a  depth  of  about  two  inches — if  dis- 
tended it  lies  somewhat  nearer  the  surface — and  can  be 
recognized  by  the  diminution  of  resistance  offered  to  the 
instrument  and  the  escape  of  fluid  along  the  groove  of  the 
director.  Drainage  is  provided  for  by  inserting  a  small 
rubber  tube  or  a  folded  strip  of  rubber  tissue. 


TREPHINING    FOR    MIDDLE    MENINGEAL     HEMORRHAGE. 

An  inverted  U-shaped  incision  is  made  from  the  upper  part 
of  the  posterior  border  of  the  frontal  process  of  the  malar. 

10* 


214  OPERATIVE  SURGERY. 

boDe  upward  nearly  to  the  temporal  ridge,  and  thence 
backward  and  downward  in  a  gentle  curve,  to  terminate  at 
the  superior  border  of  the  posterior  exremity  of  the  zygoma. 
This  flap,  including  a  part  of  the  temporal  muscle,  is 
turned  down  and  the  boue  sufficiently  bared  of  periosteum 
to  admit  the  use  of  the  trephine  at  the  spot  presently  to  be 
indicated. 

Kocher  makes  an  incision  from  the  external  angular 
process  of  the  frontal  bone  to  the  eminentia  articularis, 
thence  upward  and  backward  for  about  an  inch  in  front 
of  the  ear. 

Wagner1  employs  the  Q  flap  with  osteoplastic  resection 
of  the  skull,  the  same  as  for  exposure  of  the  second  and 
third  divisions  of  the  fifth  nerve  within  the  cranium  (see 
p.  215). 

After  the  soft  parts  have  been  raised  the  skull  is  opened 
over  the  anterior  division  of  the  artery  by  placing  the  pin 
of  a  three-quarter  inch  trephine  a  thumb's  breadth  behind 
the  external  angular  process  of  the  frontal  bone  and  two 
finger-breadths  above  the  zygoma.  Both  divisions  can 
be  exposed  simultaneously  by  applying  the  trephine  imme- 
diately above  the  middle  of  the  zygoma  (Kocher). 

Kronleiu  determines  the  location  of  the  branches  by 
drawing  a  line  through  the  upper  border  of  the  orbit 
backward  parallel  to  Reid's  base  line.  The  anterior  divi- 
sion of  the  artery  lies  on  the  upper  line  3  to  4  cm. 
behind  the  external  angular  process  of  the  frontal  bone, 
and  the  posterior  at  the  intersection  of  the  upper  line 
with  another  drawn  perpendicular  to  the  base  line  from  a 
point  3  to  4  cm.  behind  the  external  auditory  meatus — 
roughly,  from  about  the  posterior  border  of  the  mastoid 
process. 

The  following  may  be  taken  as  accurate  enough  for  all 
practical  purposes:  To  expose  the  anterior  division  of  the 
artery  apply  the  pin  of  a  three-quarter  inch  trephine  one  inch 
above  the  middle  of  the  zygoma,  and  then  enlarge  the  open- 
ing downward  with  the  rongeur  if  it  is  found  necessary  to 
secure  the  trunk  of  the  vessel.  If  for  the  latter  purpose 
the  method   l>y  osteoplastic  resection  of  the  skull  is  cra- 

i  Centralb.  f.  Chir..  1889,  p.  833. 


EXCISION  OF  JOINTS  AND  BONES.  215 

ployed,  the  bone  should  be  chiselled  through  in  the  lines  of 
the  lower  extremities  of  the  inverted  U  incision,  clown  to 
the  level  of  the  zygoma  or  nearly  to  the  pterygoid  ridge  on 
the  greater  wing  of  the  sphenoid. 

To  expose  the  posterior  division  of  the  artery  apply  the 
trephine  just  below  the  most  prominent  portion  of  the  par- 
ietal eminence. 

Any  clot  which  may  be  found  is  scooped  or  irrigated  out, 
and  the  bleeding  points  in  the  dura  are  secured  by  ligatures 
passed  around  them  by  means  of  a  fine  curved  needle. 
Hemorrhage  from  the  trunk  of  the  middle  meningeal  as  it 
lies  in  its  bony  canal  may  be  checked  by  packing  with 
gauze  or  strands  of  catgut. 


RESECTION    OF    THE    SECOND    AND    THIRD    DIVISIONS    OF 
THE   FIFTH    NERVE    WITHIN   THE   SKULL.1 

The  omega-shaped  incision  is  used  with  its  base  on  the 
zygoma  and  the  top  of  the  curved  part  at  the  temporal 
ridge.  It  starts  at  the  external  angular  process  of  the 
frontal  bone,  and  passes  horizontally  along  the  upper 
border  of  the  zygoma  for  about  half  an  inch.  Thence  in 
the  curved  portion  upward  to  the  temporal  ridge  and  down 
to  the  zygoma  and  again  horizontally  about  half  an  inch  to 
the  tragus  of  the  ear.  The  periosteum  is  divided  and  the 
bone  chiselled  through  and  turned  down  with  its  attached 
soft  parts,  as  already  described. 

The  middle  meningeal  artery  is  secured  by  passing  a 
sharply  curved  needle  and  ligature  beneath  it,  and  the  dura 
is  carefully  separated  from  the  bone  below  so  as  to  expose 
the  middle  fossa  of  the  skull.  Any  hemorrhage  is  checked 
by  pressure. 

With  broad  retractors  the  dura  and  brain  are  lifted,  taking 
great  care  to  avoid  injury  to  the  other  cranial  nerves  in 
the  immediate  vicinity.  The  first,  second,  and  third  divi- 
sions of  the  fifth  nerve,  as  well  as  the  carotid  artery  and 
cavernous  sinus  are  well  exposed.  The  dura  is  stripped 
back  from  the  second  and  third  divisions  to  beyond  the 

i  Hartley  :    N.  Y.  Med.  Journ.,  1893,  vol.  55,  p.  317. 


216  OPERA TIVE  SUBGEB Y. 

Gasserian  ganglion,  and  the  parts  lying  between  it  and  the 
foramen  ovale  and  rotundum  are  excised.  The  flap  is  then 
replaced  and  united  with  interrupted  silk  sutures. 


OPENING    OF   THE    FRONTAL    SINUS. 

The  eyebrow  is  shaved.  The  incision  starts  at  the  cen- 
tre of  the  supra-orbital  ridge  and  follows  the  curve  of  the 
upper  border  of  the  eyebrow  to  the  median  line  above  the 
root  of  the  nose.  Everything  is  divided  down  to  the  bone 
— the  periosteum  is  raised  on  each  side  and  the  trephine  or 
chisel  entered  at  the  inner  end  of  the  superciliary  ridge. 

Antrum  of  Highmore.  A  very  small  trephine  should 
be  used,  and,  in  order  to  avoid  a  scar,  it  should  be  ap- 
plied through  the  mouth  after  dividing  the  gingivo-labial 
fold,  and  dissecting  up  the  soft  parts  as  far  as  to  the  infra- 
orbital foramen,  just  below  and  to  the  outer  side  of  which 
the  opening  into  the  antrum  should  be  made. 

The  antrum  may  also  be  opened  by  drawing  the  first  or 
second  molar  tooth,  and  enlarging  its  socket  with  a  drill. 

No  additional  directions  are  needed  for  trephining  the 
Hat  bones  or  the  epiphyses  of  the  long  ones. 


PART   V.] 

NEUROTOMY  AND  TENOTOMY. 
DIVISION   AND   KESECTION   OF   NERVES. 

Division  of  a  nerve  of  sensation,  or  even  of  a  mixed 
nerve  in  extreme  cases,  may  be  required  for  the  relief  of 
neuralgic  pain.  It  is  seldom  that  simple  division  is  more 
than  temporarily  sufficient.  At  least  half  an  inch  of  the 
trunk  of  the  nerve  should  be  excised,  and,  as  additional 
security  against  reunion,  the  end  of  the  distal  segment  may 
be  bent  back  upon  itself.  Prof.  Weir  Mitchell2  has  seen 
severe  constant  pain  follow  the  bending  back  of  the  end  of 
the  proximal  segment. 

SUPRA-ORBITAL    NERVE. 

The  frontal  nerve,  main  branch  of  the  first  division  of 
the  trigeminus,  divides  just  behind  the  upper  margin  of  the 
orbit  into  the  supra-orbital  and  supra-trochlear  nerves; 
both  branches  are  distributed  to  the  forehead,  the  former 
emerging  from  the  orbit  through  the  supra-orbital  notch  or 
foramen,  the  latter  a  little  nearer  the  nose.  The  former  is 
much  the  larger  and  more  important  of  the  two,  the  latter 
supplying  only  a  narrow  strip  of  integument  near  the  me- 
dian line.  The  supra-orbital  notch  or  foramen  is  found  at 
the  junction  of  the  inner  and  middle  thirds  of  the  supra- 
orbital arch,  or  a  little  to  the  inner  side  of  the  junction. 
When  it  is  a  notch  it  can  be  readily  felt  through  the  skin, 
and  is  then  an  important  guide  in  the  operation. 

The  nerve  may  be  divided  subcutaneously  after  its  emer- 

1  A  description  of  all  known  operations  on  cranial  nerves,  with  the  bibliography, 
can  be  found  in  Chir.  Operat.  du  Syst.  Nerveux,  by  Chipault.  Paris :  Rueff  &  Co., 
1894. 

5  Oral  communication. 


218 


OPERA TIVE  S UBGER  Y. 


geuce  from  the  notch,  or  it  may  be  exposed  by  a  transverse 
incision  above  or  below  the  eyebrow. 

Subcutaneous  Division.  A  tenotomy  knife  is  entered 
between  the  eyebrows  midway  between  the  nerve  and  the 
median  line,  and  passed  horizontally  beneath  the  skin  until 
its  point  has  passed  beyond  the  nerve.  Its  edge  is  then 
turned  backward  and  pressed  against  the  bone,  and  the 
nerve,  lying  between  it  and  the  bone,  divided  by  with- 
drawing the  knife.  Or  the  knife  may  be  entered  at  the 
same  point,  but  passed  close  to  the  bone  instead  of  just 
under  the  skin,  its  edge  turned  downward  toward  the 
margin  of  the  orbit,  and  the  nerve  divided  by  sweeping 
the  knife  downward  across  the  mouth  of  the  supra-orbital 
foramen. 

Excision  of  a  Portion  of  the  Nerve.  A.  Above  the  Eye- 
brow.     (Fig.  85,  A.)     An  incision  one  to  one  and  a  half 


.1,  /;.  Resection  of  supra-orbital  nerve.    C.  Resection  of  superior  maxillary  nerve. 

inches  long  is  made  just  above  and  parallel  to  the  eyebrow, 
its  centre  corresponding  to  the  position  of  the  nerve.  This 
incision  is  carried  down  to  the  bone,  the  distal  end  of  the 
nerve  recognized,  seized   with    forceps,   dissected  out,  and 

'•111  off. 

V>.  Ilclow  the  Eyebrow.  (Fig.  85,  B.)  The  eyebrow 
being  drawn  up  and  the  eyelid  down,  the  surgeon  makes  an 
incision  one  to  one  ;iinl  a  half  inches  in  length  along  the 
edge  of  the  supra-orbital  arch, dividing  successively  the  skin, 
orbicular  muscle,  and  tarsal  ligament,     lie  then  seeks  the 


NE  UR  0  TO  MY  A  ND  TENO  TOMY.  219 

nerve  in  the  notch,  traces  it  back  as  far  as  necessary,  while 
depressing  the  eye  and  levator  palpebral  with  a  retractor, 
and  cuts  out  a  portion  with  curved  scissors. 

Swpra-trochlear  Nerve.  Konig  resected  this  nerve  by 
making  a  curved  incision  under  the  eyebrow  at  the  upper 
inner  edge  of  the  orbit,  and  seeking  the  trochlea  and  the 
superior  oblique  muscle.  On  making  the  latter  tense  with 
a  hook  the  two  fine  nerves  became  visible,  were  seized  with 
forceps,  and  resected. 

SUPERIOR   MAXILLARY   NERVE. 

After  leaving  the  cavity  of  the  cranium  by  the  foramen 
rotundum,  the  superior  maxillary  nerve  crosses  the  spheno- 
maxillary fossa,  traverses  the  infra-orbital  canal,  and  ap- 
pears upon  the  face  at  the  infra-orbital  foramen,  where  it 
at  once  divides^up  into  numerous  branches  distributed  over 
the  cheek,  nose,  lip,  and  lower  eyelid.  Within  the  infra- 
orbital canal  it  gives  off  the  anterior  dental  branch,  and 
posterior  to  this  canal  it  gives  off  the  posterior  dental,  and 
through  branches  to  the  spheno-palatine  ganglion,  the  pala- 
tine nerves  distributed  to  the  palate  and  nasal  fossa.  The 
point  at  which  the  nerve  should  be  divided  will  vary  accord- 
ing to  the  region  affected ;  but  in  this,  as  in  other  cases, 
simple  division  has  usually  proved  insufficient,  and  it  has 
been  found  necessary  to  excise  all  that  portion  of  the  trunk 
which  lies  in  the  canal.  Sometimes  the  nerve  has  been 
cut  above  the  branches  going  to  the  ganglion,  and  the  latter 
torn  out  forcibly. 

The  roof  of  the  infra-orbital  canal  is  composed  in  its  pos- 
terior half  of  fibrous  tissue,  in  its  anterior  half  of  thin  bone, 
which  becomes  thicker  as  it  approaches  the  margin  of  the 
orbit.  The  infra-orbital  foramen  lies  directly  above  the 
second  bicuspid  tooth  and  from  one-quarter  to  one-half  an 
inch  below  the  margin  of  the  orbit.  The  nerve  is  accom- 
panied on  its  passage  through  the  canal  by  the  infra-orbital 
artery. 

A.  Division  of  the  Nerve  on  the  Face.  This  may  be 
done:  (1)  subcutaneously ;  (2)  through  the  mouth;  (3)  by 
an  external  incision. 


220  OPERATIVE  SURGERY. 

1.  Subcutaneously.  A  tenotomy  knife  is  entered  about 
an  inch  to  the  outer  side  of  the  foramen,  carried  below  it 
into  the  canine  fossa,  hugging  the  bone,  and  then  swept 
upward  along  the  surface  of  the  bone  so  as  to  divide  the 
nerve  close  to  the  foramen,  the  lip  being  drawn  downward 
and  forward  to  make  the  tissues  tense. 

2.  Through  the  Mouth.  An  incision  is  made  in  the 
gingivo-labial  fold,  and  the  soft  parts  dissected  away  from 
the  bone  until  the  nerve  is  reached  and  divided.  Guerin 
advises  that  a  small  portion  of  the  distal  eud  be  excised. 

3.  By  External  Incision.  The  incision  may  be  trans- 
verse, oblique,  or  curved ;  it  is  only  necessary  that  its  centre 
should  correspond  to  the  foramen.  The  tissues  are  divided 
successively  until  the  bone  is  reached  and  the  nerve  found 
either  by  following  up  one  of  its  branches  or  by  seeking  it 
at  its  point  of  emergence. 

B.  Resection  of  the  Infra-orbital  Portion.  (Tillaux1). 
Fig.  85,  C.  A  vertical  incision  is  made  along  the  side  of 
the  nose  from  the  lachrymal  tubercle  or  the  bony  ridge  of 
the  nasal  process  of  the  superior  maxilla,  which  is  contin- 
uous with  the  lower  edge  of  the  orbit,  down  to  the  ala  of 
the  nose.  A  second  horizontal  one  is  then  begun  at  the 
upper  portion  of  the  first  and  carried  outward  along  the 
lower  margin  of  the  orbit  beyond  its  centre.  These  inci- 
sions should  involve  all  the  soft  parts  down  to  the  bone. 
The  lower  flap  is  dissected  up,  the  nerve  found,  and  a  silk 
ligature  thrown  around  it  close  to  the  foramen. 

The  upper  flap  is  then  raised,  together  with  the  lower 
eyelid  and  eyeball,  exposing  the  floor  of  the  orbit  as  far 
back  as  possible,  upon  which  the  infra-orbital  canal  can  be 
recognized  as  a  grayish  line  running  obliquely  backward 
and  inward. 

The  canal  is  opened  with  a  knife  or  chisel,  the  nerve 
isolated  from  the  artery,  raised  from  its  bed  with  a  small 
hook,  and  dissected  out  as  far  back  as  may  be  considered 
necessary.  It  is  then  divided  with  curved  scissors,  and  the 
distal  portion  drawn  out  by  means  of  the  ligature  applied 


1  Traite  d'Anat.  Topographique,  p.  310,  and  Bull.de  la  Soci6t0  do  Chirurgie. 
■     08. 


NEUROTOMY  AND  TENOTOMY.  221 

to  it  iu  the  beginning.     The  length  of  the  portion  removed 
by  Tillaux  was  six  centimetres. 

Dolbeau1  divided  the  nerve  with  curved  scissors  on  the 
central  side  of  the  branches  going  to  the  spheno- palatine 
ganglion,  and  tore  out  the  ganglion  by  drawing  upon  the 
nerve. 

Malgaine's  Method.  Pass  a  stout  tenotome  along  the 
floor  of  the  orbit  for  nearly  an  inch  in  the  direction  of  the 
nerve ;  cut  transversely  with  its  point  through  the  floor  of 
the  orbit;  the  bone  being  thin  will  offer  no  resistance.  This 
divides  both  canal  and  nerve.  Expose  the  nerve  at  the 
infra-orbital  foramen  by  a  simple  transverse  incision,  seize 
it  with  forceps  and  tear  it  out  of  the  canal. 

The  first  part  of  this  operation  has  been  modified  by  Von 
Langenbeck  and  Hueter  as  follows :  A  strong  tenotome  with 
slightly  blunted  point  is  entered  close  below  the  external 
palpebral  ligament  and  pushed  backward  and  downward 
along  the  outer  wall  of  the  orbit  until  its  point  is  felt  to 
leave  the  bone  and  enter  the  fissure;  its  edge  is  then  turned 
forward  against  the  sharp  border  of  the  orbital  process  of 
the  superior  maxilla  and  made  to  scrape  along  it  as  the 
knife  is  brought  forward. 

Lucke's  Method.2  An  incision,  beginning  one  centimetre 
above  the  outer  angle  of  the  eye  and  close  behind  the  margin 
of  the  orbit,  is  carried  downward  and  slightly  forward  across 
the  malar  bone,  dividing  its  periosteum ;  from  its  lower  end 
a  second  incision  is  carried  backward  and  upward,  terminat- 
ing over  the  outer  surface  of  the  zygomatic  process  of  the 
temporal,  about  a  quarter  of  an  inch  behind  its  junction  with 
the  malar  bone.  The  latter  bone  is  next  divided  in  the  line 
of  the  first  incision  by  means  of  a  saw  or  chisel,  after  pre- 
liminary division  of  the  soft  parts  and  periosteum  on  its 
under  and  inner  surface  with  a  small  knife,  and  the  zygoma 
then  cut  through  at  its  posterior  extremity.  The  attach- 
ments of  the  masseter  to  the  intermediate  piece  are  then 
separated,  and  the  flap  of  bone  and  soft  parts  raised  with  a 
sharp  hook. 

If  necessary,  some  of  the  anterior  fibres  of  the  temporal 
muscle  should  now  be  divided  in  order  to  expose  the  spheno- 

1  Oral  communication. 

-  Deutsche  Zeitschrift  fur  Chirurgie,  vol.  4,  p.  322. 


222  OPERATIVE  SURGERY. 

maxillary  fossa  thoroughly,  the  fat  occupying  the  fossa 
pressed  backward  with  a  retractor,  and  the  sphenomaxil- 
lary fissure  recognized  with  a  probe.  The  nerve  and  artery 
can  be  distinguished  by  the  difference  in  their  course,  the 
former  running  downward,  outward,  and  forward,  the  latter 
upward,  inward,  and  forward.  The  nerve  is  seized  with 
forceps  and  divided  with  a  tenotome  well  forward  in  the  fis- 
sure, and  then  again  with  scissors  as  near  as  possible  to  the 
foramen  rotundum.  The  flap  is  then  put  back,  and  the 
wound  drained  at  it  lower  angle. 

An  objection  to  this  method  is  that,  iu  consequence  of  its 
interference  with  the  masseter  and  temporal  muscles,  the 
mouth  subsequently  cannot  be  freely  opened.  Lossen  and 
Braun1  avoid  this  difficulty  by  leaving  the  attachments  of 
the  masseter  untouched  and  turning  the  flap  downward  in- 
stead of  upward,  after  making  the  second  incision  from  the 
upper  end  of  the  first  instead  of  from  its  lower  end,  and 
separating  the  temporal  fascia  from  the  malar  bone. 
Czerny2  has  employed  this  modification  five  times  with  good 
results. 

If  wounded  vessels  cannot  be  seized  and  tied,  the  hemor- 
rhage must  be  arrested  by  plugging  with  antiseptic  gauze. 


INFERIOR  DENTAL  NERVE. 

This  nerve  may  be  divided  (A)  after  its  exit  from  the 
dental  canal,  (B)  in  the  canal,  (C)  before  its  entrance  into 
the  canal.  The  nerve  enters  the  canal  by  the  inferior 
dental  foramen  on  the  inner  side  of  the  ascending  ramus  of 
the  lower  jaw  at  the  level  of  the  crowns  of  the  lower  teeth  ; 
the  canal  runs  obliquely  downward  and  forward  just  below 
the  alveoli,  and  the  nerve  emerges  through  the  mental  fora- 
men which  lies  midway  between  the  alveolar  process  and 
the  lower  margin  of  the  jaw  below  the  second  bicuspid 
tooth. 

A.  At  the  Mental  Foramen.  An  incision  is  made  in  the 
gingivo-labial  fold  above  the  foramen,  and  the  soft  parts 

1  < :oiitmlljlatt  fUr  Ohirurgie,  1878,  pp.  05  and  148.  2  ibid.,  1882,  p.  249. 


NEUROTOMY  AND  TENOTOMY.  223 

dissected  off  until  the  nerve  is  reached,  usually  about  one- 
third  of  an  inch  below  the  bottom  of  the  fold. 

B.  Within  the  Canal.  An  incision  is  made  through  the 
skin  down  to  the  bone  along  the  course  of  the  nerve  in 
front  of  the  masseter,  the  periosteum  raised,  and  the  canal 
opened  with  a  chisel  or  small  trephine.  After  removal  of 
the  outer  table  of  the  bone  the  nerve  is  easily  found  in  the 
canal  and  divided. 

Or  the  canal  may  be  opened  at  two  points  and  the  inter- 
mediate portion  of  the  nerve  excised. 

A  better  method  is  to  make  a  curved  incision  behind  and 
below  the  angle  of  the  jaw,  and  elevate  the  periosteum  and 
masseter  on  its  outer  surface  as  far  as  the  alveolar  margin. 
Then  chisel  into  the  middle  of  the  exposed  bone.  The  oral 
cavity  should  not  be  opened. 

C.  Before  its  Entry  into  the  Canal.  1.  From  within  the 
mouth.  The  mouth  being  held  widely  open  and  the  com- 
missure of  the  lips  drawn  backward  and  outward,  an  inci- 
sion extending  from  the  last  upper  to  the  last  lower  molar 
tooth  is  made  one-third  of  an  inch  on  the  inner  side  of  the 
sharp  anterior  border  of  the  coronoid  process,  and  carried 
through  the  mucous  membrane  to  the  tendon  of  the  temporal 
muscle. 

The  surgeon  passes  his  finger  into  the  incision  and  along 
the  inner  surface  of  the  bone,  between  it  and  the  internal 
pterygoid  muscle,  until  he  touches  the  bony  point  which 
marks  the  orifice  of  the  canal.  Passing  a  blunt  hook  along 
the  finger,  he  raises  the  nerve  upon  it,  isolating  it,  if  possi- 
ble, from  the  accompanying  artery,  and  divides  it  with 
blunt-pointed  scissors  or  knife.  Or,  without  introducing 
the  finger,  the  hook  may  be  passed  back  beyond  the  nerve, 
its  point  constantly  in  contact  with  the  bone,  then  rotated 
inward  so  as  to  carry  its  point  across  and  behind  the  nerve, 
and  then  withdrawn. 

2.  Through  the  cheeh.  A  curved  incision  is  made  around 
the  angle  of  the  jaw  or  around  the  lower  anterior  insertion 
of  the  masseter  and  carried  through  to  the  bone  along  its 
lower  portion  ;  then  with  the  elevator  and  knife  the  muscle 
is  detached  from  below  upward,  and  the  flap  raised  with  a 


224  OPERATIVE  SURGERY. 

hook  until  the  level  of  the  inferior  dental  foramen  is  reached. 
The  bone  is  then  cut  away  with  a  chisel  or  small  trephine 
and  the  nerve  exposed  and  excised. 

With  the  same  curved  incision  around  the  angle  of  the 
jaw  the  inner  surface  of  the  latter  may  be  freed  from  the 
periosteum  and  internal  pterygoid  muscle  upward  till  the 
lingula  is  felt.  Then,  with  or  without  dividing  this  pro- 
cess the  nerve  can  be  isolated  and  divided,  or  a  vertical  in- 
cision may  be  made  through  the  skin  and  fascia,  the  fibres 
of  the  masseter  separated,  and  the  bone  thus  exposed. 

At  the  Foramen  Ovale.  Braun's  modification  of  Liicke's 
method  for  exposing  the  superior  maxillary  nerve  can  be 
employed  with  slight  changes  for  this  purpose.  The  tem- 
poral muscle  must  be  retracted  or  partially  divided  near 
its  insertion,  or  the  coronoid  process  cut  through  at  its 
base. 

Kronlein1  suggests  the  following  method  :  An  incision  is 
made  from  half  an  inch  behind  the  angle  of  the  mouth  to 
terminate  a  similar  distance  in  front  of  the  lobule  of  the 
ear.  Only  the  skin  and  subcutaneous  fat  are  divided,  the 
buccinator  and  oral  mucous  membrane  being  spared.  The 
masseter  is  cut  back  to  the  anterior  border  of  the  parotid 
gland,  thus  sparing  the  latter  and  Steno's  duct,  which  lies 
well  above  the  line  of  incision.  The  coronoid  process  is 
bared  at  its  base  with  a  periosteal  elevator,  divided  from 
the  semilunar  notch  downward  and  forward,  and  drawn 
upward,  together  with  the  attached  temporal  muscle.  The 
branches  of  the  inferior  maxillary  nerve  are  then  exposed  by 
a  blunt  dissection  on  the  outer  surface  of  the  internal  ptery- 
goid muscle.  The  external  pterygoid  is  drawn  upward  and 
the  nerves  traced  back  to  the  base  of  the  skull.  At  the 
close  of  the  operation  the  coronoid  process  and  divided 
masseter  muscle  are  sutured. 

He  exposes  the  superior  and  inferior  maxillary  nerves 
simultaneously  at  their  exit  from  the  skull  iu  the  following 
manner  :2  A  curved  incision,  concavity  upward,  is  made, 
starting  from  the  most  prominent  portion  of  the  malar  bone, 
passing  down  to  the  level   of  the  lobule  of  the  ear,  thence 

1  Archly,  f.  fclin.  Chir..  Bd.  xliii.  p.  13. 

a  Deutecb.  Zeltech.  f.  chir.,  1884,  vol.  xx.  p.  484. 


NEUROTOMY  AND  TENOTOMY.  225 

backward  and  upward  in  a  gentle  curve,  to  terminate  over 
the  posterior  extremity  of  the  zygoma.  The  flap  of  skin 
and  subcutaneous  fascia  is  turned  up,  the  temporal  fascia 
divided  along  the  upper  border  of  the  zygoma,  aud  the  latter 
sawn  through  at  its  anterior  and  posterior  extremities,  as  in 
Liicke's  operation.  The  coronoid  process  is  exposed  and 
cut  through  at  its  base  downward  and  forward,  and  drawn 
upward  with  the  attached  temporal  muscle.  The  internal 
maxillary  artery  is  secured  and  the  attachment  of  the  exter- 
nal pterygoid  muscle  separated  from  the  under  surface  of 
sphenoid  bone.  This  exposes  the  inferior  maxillary  nerve 
at  the  foramen  ovale,  and  by  working  along  the  spheno- 
maxillary fissure  the  superior  maxillary  nerve  is  found  and 
followed  back  to  the  foramen  rotundum.  At  the  close  of 
the  operation  the  parts  are  replaced  and  sutured  in  their 
proper  position. 

Salger1  recommends  a  curved  incision,  convexity  upward, 
extending  from  one  extremity  of  the  zygoma  to  the  other. 
Everything  is  divided  down  to  the  skull,  the  zygoma  sawn 
through  at  each  extremity,  and  the  flap  of  skin,  fascia,  tem- 
poral muscle,  aud  zygoma  turned  down.  The  coronoid  pro- 
cess is  depressed  by  opening  the  mouth,  and  the  nerve  found 
below  the  external  and  on  the  outer  surface  of  the  internal 
pterygoid  muscle,  and  divided  as  high  up  as  desired. 


BUCCAL   NERVE. 

The  buccal  nerve,  a  branch  of  the  inferior  maxillary,  is 
not  infrequently  the  seat  of  painful  and  persistent  neuralgia. 
It  is  best  approached  through  the  mouth  by  the  following 
method : 

The  surgeon  places  his  finger-nail  upou  the  outer  lip  of 
the  anterior  border  of  the  ascending  ramus  of  the  lower 
jaw  at  its  centre,  and  divides  in  front  of  this  border  the 
mucous  membrane  and  the  fibres  of  the  buccinator  verti- 
cally. He  then  seeks  for  the  nerve,  separating  the  tissues 
with  a  director,  and  divides  it. 

Zuckerkandl  exposes  the  nerve  from  the  outside  of  the 

1  Wien.  med.  Wochenschr.,  1887,  vol.  xxsvii.  p.  461. 


226  OPERATIVE  SURGERY. 

cheek.  A  horizontal  incision  a  finger's  breadth  below  the 
zygoma  is  made  from  the  anterior  border  of  the  masseter 
muscle  nearly  to  the  canine  eminence.  The  fascia  overly- 
ing Steno's  duct  is  divided,  and  the  latter  exposed  and 
drawn  downward  with  its  accompanying  nerves.  The  fat 
on  the  posterior  part  of  the  buccinator  muscle  is  torn 
through,  and  the  nerve  found  to  the  inner  side  of  the  inser- 
tion of  the  temporal  muscle  on  the  front  of  the  coronoid 
process.  It  lies  about  an  inch  back  of  the  anterior  border 
of  the  masseter  muscle. 


LINGUAL   NERVE. 

Division  of  this  nerve  may  be  required  for  the  relief  of 
pain  in  cases  of  carcinoma  of  the  tongue. 

When  the  mouth  is  opened  widely  the  pterygo-maxillary 
ligament  can  be  readily  seen  and  felt  as  a  prominent  fold 
behind  the  last  lower  molar,  and  the  lingual  nerve  can  be 
felt  just  below  the  attachment  of  the  ligament  on  the  inner 
side  of  the  lower  jaw,  close  to  the  bone  below  the  last  molar 
tooth. 

The  tongue  should  be  drawn  aside  by  an  assistant,  the 
mucous  membrane  divided  for  about  an  inch  parallel  to  the 
margin  of  the  alveolar  process,  beginning  at  the  last  molar 
tooth  over  the  position  of  the  nerve,  or,  according  to  Chau- 
vel,1  one-fifth  of  an  inch  from  the  attachment  of  the  mucous 
membrane  to  the  side  of  the  tongue.  The  nerve  is  then 
readily  found  in  the  submucous  tissue,  raised  upon  a  hook 
and  divided,  or  a  portion  excised. 

Moore's  Method.  Mr.  Moore  has  employed  the  follow- 
ing method  successfully  in  five  cases  :  He  cuts  the  nerve 
about  half  an  inch  from  the  last  molar  tooth,  at  a  point 
where  it  crosses  an  imaginary  line  drawn  from  that  tooth 
to  the  angle  of  the  jaw.  He  enters  the  point  of  the  knife 
nearly  three-quarters  of  an  inch  behind  and  below  the  tooth, 
presses  if  down  to  the  bone  and  cuts  toward  the  tooth.  This 
necessarily  divides  the  nerve.     This  projection  of  the  alve- 

1  Prtcls  d'Opirationa  de  Cblrurgie,  p.  435. 


NEUROTOMY  AND  TENOTOMY.  227 

olar  ridge  might  protect  the  nerve  from  a  straight  bistoury, 
and  therefore  a  curved  one  should  be  used. 

The  lingual  nerve  may  also  be  readied  from  outside  the 
mouth  by  any  one  of  the  methods  for  resecting  the  inferior 
maxillary,  or  by  an  incision  aloug  the  lower  border  of  the 
jaw  just  in  front  of  the  masseter  muscle.  In  the  latter 
case  (Lobker)  the  upper  margin  of  the  wound  is  drawn 
up  and  a  portion  of  the  inferior  maxilla,  where  the  alveolar 
process  adjoins  the  ramus,  is  exsected  and  the  nerve  ex- 
posed on  the  outer  surface  of  the  internal  pterygoid.  Or 
the  dissection  can  be  carried  up  under  the  inner  surface  of 
the  jaw  (Luschka).  The  submaxillary  gland  is  displaced 
downward  and  forward,  the  posterior  border  of  the  mylo- 
hyoid muscle  divided  and  the  nerve  found  under  the  pos- 
terior end  of  the  sublingual  gland.  Thence  it  can  be  fol- 
lowed backward  and  upward  and  divided  as  high  as 
desired. 

FACIAL   NERVE. 

This  nerve  has  occasionally  been  stretched  and  crushed 
for  the  relief  of  clonic  spasms  of  the  corresponding  mus- 
cles. A  semilunar  incision  is  made  around  the  lower 
attachment  of  the  ear  with  a  short  liberating  incision  down- 
ward from  its  centre;  the  flaps  are  dissected  back,  and  the 
nerve  exposed  by  drawing  the  parotid  forward  and  out- 
ward. 

The  nerve  is  more  easily  exposed  at  the  posterior  border 
of  the  ramus.  For  this  an  incision  is  made  from  just  in  front 
of  the  tragus  of  the  ear  to  the  angle  of  the  jaw.  After 
dividing  the  parotid  fascia  the  cervico-facial  branch  will 
probably  be  exposed  first,  and  can  then  be  followed  back 
to  its  junction  with  the  temporo-facial. 


BRACHIAL   PLEXUS. 

Tins  plexus  consists  of  the  four  lower  cervical  nerves 
and  the  greater  part  of  the  first  dorsal.  It  crosses  the 
floor  of  the  subclavian  triangle  of  the  neck,  and  lies  be- 
tween the  anterior  and  middle  scaleni  muscles.     Its  shape 


228  OPERATIVE  SURGERY. 

is  triangular,  with  the  base  at  the  spiue  and  the  apex  to  the 
outer  side  of  the  subclavian  artery  below  the  clavicle. 

Operation.  The  head  and  neck  are  extended,  and  the 
face  turned  to  the  opposite  side.  An  incision,  starting  half 
an  inch  above  the  clavicle  in  the  interval  between  the  sterno- 
cleido-mastoid  and  trapezius,  is  carried  forward,  for  about 
three  inches,  parallel  to  the  anterior  border  of  the  latter. 
The  skin  and  platysma  are  divided  and  the  external  jugular 
vein  either  cut  between  two  ligatures  or  drawn  to  one  side. 
The  deep  cervical  fascia  is  divided  in  the  line  of  the  external 
incision,  avoiding  the  supra-clavicular  branches  of  the  cer- 
vical plexus,  and  the  outer  border  of  the  anterior  scalenus 
muscle  recognized.  The  plexus  is  felt  with  the  finger  just 
outside  the  latter  and  isolated  by  a  little  careful  dissection. 
Any  particular  cord  can  be  identified  by  tracing  it  to  its 
point  of  emergence  from  the  spine  through  the  interval 
between  the  scaleni  muscles. 

Resection  of  the  posterior  roots  of  the  brachial  plexus. 
This  operation  has  been  performed  several  times  for 
severe  neuralgia  of  the  peripheral  branches.  An  incision 
about  six  iuches  long,  with  its  centre  just  above  the  spine  of 
the  seventh  cervical  vertebra,  is  made  parallel  and  close  to 
the  ligamentum  nuchas  and  deepened  alongside  of  the  spines 
till  the  laminse  of  the  fifth,  sixth,  and  seventh  vertebra? 
are  reached.  These  lamina?  are  then  bared  of  soft  parts  on 
the  affected  side  out  to  the  bases  of  the  articular  processes, 
and  removed  with  the  chisel,  rongeur,  or  bone  forceps, 
thus  exposing  the  posterior  roots  of  the  nerves  previous  to 
their  exit  from  the  intervertebral  foramina. 


CERVICAL   PLEXUS. 

An  incision  about  two  inches  in  length  is  made  parallel 
to  and  over  the  posterior  border  of  the  sterno-mastoid 
muscle.  Its  centre  should  correspond  to  the  centre  of  the 
muscle.  The  skin,  superficial  fascia,  and  platysma  are 
divided  and  the  superficial  branches  of  the  cervical  plexus 
are  exposed  at  the  middle  of  the  posterior  border  of  the 


NEUROTOMY  AND  TENOTOMY.  229 

sterno-mastoid  muscle  and  can  be  traced  back  toward  the 
spine. 

SPINAL   ACCESSORY   NERVE. 

Anatomy.  After  passing  outward  beneath  the  digastric 
and  stylo-hyoid  muscles  and  occipital  artery,  the  nerve 
about  half  an  inch  below  the  apex  of  the  mastoid  process 
enters  the  under  surface  of  the  sterno-mastoid  muscle  in  its 
upper  part,  leaves  it  at  about  the  centre  of  its  posterior 
border,  and  passes  beneath  the  trapezius  at  about  the  junc- 
tion of  the  middle  and  lower  thirds  of  its  anterior  border. 
In  the  substance  of  the  sterno-mastoid  muscle  it  commu- 
nicates with  the  second  cervical  nerve,  in  the  occipital 
triangle  with  the  second  and  third,  and  beneath  the  trape- 
zius with  the  third  and  fourth  cervical  nerves. 

Operation.  An  incision  about  three  inches  in  extent  is 
made  downward  from  the  tip  of  the  mastoid  process  along 
the  auterior  border  of  the  sterno-mastoid  muscle,  the  cervi- 
cal fascia  divided,  and  the  muscle  strongly  retracted  to  put 
the  nerve  on  the  stretch.  The  nerve  is  then  sought  for 
external  to  the  jugular  vein  about  an  inch  and  a  half  be- 
low the  tip  of  the  mastoid  process  on  the  fascia  covering 
the  rectus  capitis  anticus  major.  If  it  is  not  immediately 
apparent  the  nail  of  the  index  finger  may  be  drawn  across 
the  bottom  of  the  dissection  to  irritate  the  filaments  (recog- 
nized by  contraction  of  the  sterno-mastoid  and  trapezius 
muscles),  and  thus  help  to  locate  the  nerve. 

Section  of  the  posterior  divisions  of  the  first,  second,  and 
third  cervical  nerves  for  spasmodic  wry  neck.  The  chief 
posterior  cervical  rotators  of  the  head  and  their  nerve  sup- 
ply are  as  follows  :  The  rectus  capitis  posticus  major  is 
supplied  by  the  suboccipital  or  posterior  division  of  the 
first  cervical  nerve.  The  inferior  oblique  is  supplied  by 
the  posterior  divisions  of  the  first  and  second  cervical 
nerves,  and  the  splenitis  capitis  by  the  posterior  divisions 
of  the  second  and  third  cervical  nerves. 

Operation.     (Modified  from  Keen.)1     A  transverse  in- 

i  Annals  Surg.,  Jan.,  1891. 
11 


230  OPERATIVE  SURGERY. 

cision  about  three  inches  long  is  made  extending  hori- 
zontally outward  from  the  middle  line  of  the  neck,  or 
slightly  overlapping  it,  an  inch  and  a  half  below  the  ex- 
ternal occipital  protuberance.  It  is  carried  through  the 
trapezius  and  posterior  border  of  the  splenius  capitis  mus- 
cles until  the  complexus  is  recognized ;  the  trapezius  is 
dissected  up  from  the  complexus,  and  the  occipitalis  major 
nerve  found  at  the  upper  part  of  the  complexus.  Divide 
the  complexus  transversely  and  follow  the  nerve  back  to 
its  origin  from  the  posterior  division  of  the  second  cervi- 
cal nerve,  and  divide  the  latter  as  near  the  vertebra  as 
possible. 

Recognize  the  suboccipital  triangle,  which  is  bounded 
by  the  superior  and  inferior  oblique  and  the  rectus  capitis 
posticus  major  muscles.  Within  this  lies  the  suboccipital 
nerve  close  to  the  occiput  and  vertebral  artery  ;  it  must  be 
traced  and  severed  close  to  the  spine.  The  posterior  divi- 
sion of  the  third  cervical  nerve  is  found  beneath  the  com- 
plexus about  an  inch  lower  down  than  the  occipitalis  major, 
and  must  be  cut  close  to  the  bifurcation  of  the  main  trunk. 

Smith1  made  a  longitudinal  incision  about  three  inches 
long  from  the  occiput  downward  about  an  inch  and  a  half 
to  one  side  of  the  middle  line.  It  passed  through  the 
trapezius  to  the  edge  of  the  splenius,  then  through  the 
complexus,  and  eventually  exposed  the  posterior  divisions 
of  the  cervical  nerves.  The  great  occipital  nerve  was 
recognized,  separated,  and  drawn  aside ;  a  part  of  the 
external  branch  of  the  posterior  division  of  the  second 
nerve  was  excised ;  the  splenius  and  complexus  separated 
from  the  parts  beneath,  and  the  entering  nerve  filaments 
divided. 

The  suboccipital  nerve  was  not  divided.  The  result  of 
this  operation  seems  to  have  been  perfect. 

Median  Nerve.  In  the  arm  it  is  exposed  by  the  method 
given  for  ligation  of  the  brachial  artery.  At  the  wrist  it 
is  reached  by  an  incision  about  an  inch  and  a  half  long, 
parallel  to  and  just  to  the  ulnar  side  of  the  tendon  of  the 
pal  maris  longus. 

»  Brit.  Med.  Journ.,  1891,  vol.  1,  p.  752. 


NEUROTOMY  AND  TENOTOMY.  231 

Ulnar  Nerve.  Except  in  the  extreme  upper  part  of  its 
course  the  nerve  closely  accompanies  the  triceps  and  is 
completely  separated  from  the  median  nerve  and  brachial 
artery  by  the  fascial  septum  that  passes  down  to  the  bone 
between  the  biceps  and  triceps.  Except  near  the  elbow,  it 
should  be  sought  through  an  incision  parallel  to  and  a 
little  posterior  to  the  brachial  artery,  and  after  exposure  of 
the  triceps. 

Above  the  elbow  it  can  be  easily  found  through  an  in- 
cision an  inch  and  a  half  long,  curving  upward  between 
the  internal  epicondyle  and  the  olecranon. 

In  the  forearm  its  course  is  indicated  by  a  line  drawn 
from  the  space  between  the  internal  epicondyle  and  the 
olecranon  to  the  radial  side  of  the  pisiform  bone.  At  first, 
it  lies  over  the  flexor  profundus  beneath  the  flexor  carpi 
ulnaris.  At  the  wrist  it  is  superficial,  and  lies  on  the  annu- 
lar ligament  with  the  ulnar  artery  on  its  radial  side.  It  is 
easily  reached  at  the  wrist  by  an  incision  about  two  inches 
long  extending  upward  through  the  skin  and  fascia  from 
the  pisiform  bone.  The  incision  is  parallel  to  and  close  to 
the  radial  side  of  the  flexor  carpi  ulnaris  tendon. 


MUSCULO-SPIRAL   NERVE. 

Anatomy.  It  winds  around  the  humerus  in  the  mus- 
culo-spiral  groove  between  the  internal  and  external  heads 
of  the  triceps,  and  reaches  the  outer  side  of  the  arm  at 
about  the  junction  of  the  middle  and  lower  thirds,  and  is 
accompanied  by  the  superior  profunda  artery.  It  then 
pierces  the  external  intermuscular  septum  and  descends  in 
the  groove  between  the  brachialis  anticus  and  supinator 
longus  to  the  front  of  the  external  condyle.  At  this  point 
it  is  most  easily  found. 

Operation.  An  incision  about  three  inches  long  is  made 
at  the  upper  part  of  the  supinator  groove,  the  fascia  di- 
vided, and  the  nerve  sought  iu  the  bottom  of  the  groove  ; 
it  is  then  followed  upward  or  downward,  according  to  the 
circumstances  of  the  case. 


232  OPERATIVE  SURGERY. 

Great  Sciatic  Nerve.  An  incision  three  or  four  inches 
long  is  made  vertically  downward  from  the  gluteal  fold, 
midway  between  the  tuberosity  of  the  ischium  and  the 
great  trochanter.  After  division  of  the  skin  and  fascia 
the  lower  border  of  the  gluteus  maximus  is  observed  and 
the  hamstring  muscles  recognized. 

The  nerve  lies  on  the  external  rotators  of  the  thigh 
just  in  front  of  and  to  the  outer  side  of  the  hamstring 
muscles. 

Internal  Popliteal  Nerve.  It  is  reached  by  the  incision 
for  ligation  of  the  popliteal  artery.  It  is  superficial  to  the 
vein  and  artery  and  slightly  external. 

External  Popliteal  Nerve.  This  nerve  lies  close  behind 
and  to  the  inner  side  of  the  tendon  of  the  biceps,  and  is 
exposed  by  an  incision  two  or  three  inches  long  parallel  to 
and  close  to  the  inner  side  of  that  tendon. 

Anterior  Crural  Nerve.  A  longitudinal  incision  about 
two  inches  in  length  is  made  downward  from  Poupart's 
ligament,  about  an  inch  to  the  outer  side  of  the  femoral 
artery.  The  superficial  circumflex  iliac  vessels  will  be 
divided  ;  the  nerve  will  be  found  close  beneath  the  fascia. 


NEURORRHAPHY. 

I.  Primary  Suture.  An  incision  is  made  in  the  course 
of  the  nerve,  exposing  it  at  the  point  of  division.  The 
ends  are  brought  together  by  a  couple  of  fine  sutures  of 
silk  or  catgut  passed  directly  through  the  substance  of  the 
nerve  or  through  the  nerve  sheath.  They  must  be  so 
placed  and  tied  as  not  to  strangulate  the  fibres. 

II.  Secondary  Suture.  A  long  incision  will  probably 
be  necessary  ;  it  should  be  made  in  the  normal  course  of 
the  nerve  and  extend  well  above  and  below  the  point  of 
division.  The  trunk  of  the  nerve  should  be  sought  for 
both  above  and  below  the  cicatricial  tissue  of  the  original 


NEUROTOMY  AND  TENOTOMY.  233 

wound,  and  traced  downward  and  upward  respectively  to 
the  divided  and  separated  ends.  Such  part  of  each  end 
as  is  bulbous  or  imbedded  in  cicatricial  tissue  should  be 
cut  away  and  the  divided  surfaces  brought  iuto  apposition 
and  sutured.  Tension  should  be  relieved  by  freeing  the 
nerve  above  and  below  and  by  flexing  adjoining  joints. 

It  is  not  absolutely  necessary  to  success  that  the  divided 
ends  should  be  brought  close  together ;  reunion  has  taken 
place  across  gaps  of  considerable  length,  one  or  two  centi- 
metres ;  it  has  been  thought  to  be  favored  under  such  cir- 
cumstances by  the  presence  of  a  suture  connecting  the  two 
ends. 

When  there  has  been  a  considerable  loss  of  nerve  sub- 
stance, rendering  it  impossible  to  bring  the  divided  ends  near 
together,  flaps  have  been  cut  from  the  proximal  and  dis- 
tal stumps  and  unfolded,  and  their  extremities  united  as  in 
tenorrhaphy  (Fig.  90) ;  or  the  distal  stump  may  be  freshened 
and  then  inserted  and  sutured  between  the  fibres  of  a 
neighboring  uninjured  nerve  of  similar,  or  at  least  partly 
similar,  character. 

TENOTOMY. 

Professor  Sayre,1  in  answering  the  question,  How  are  we 
to  determine  whether,  in  any  given  case,  we  shall  be  com- 
pelled to  resort  to  tenotomy?  lays  down  the  following  rule 
as  of  universal  application  : 

"Place  the  part  contracted  as  nearly  as  possible  in  its 
normal  position,  by  means  of  manual  tension  gradually 
applied,  and  then  carefully  retain  it  in  that  position ;  while 
the  parts  are  thus  placed  upon  the  stretch,  make  additional 
point-pressure  with  the  end  of  the.finger  upon  the  parts 
thus  rendered  tense,  and  if  such  additional  pressure  pro- 
duces reflex  contractions,  that  tendon,  fascia,  or  muscle 
must  be  divided,  and  the  point  at  which  the  reflex  spasm 
is  excited  (the  point  at  which  the  pressure  is  applied)  is 
the  point  where  the  operation  should  be  performed." 

According  to  Prof.  Sayre,  the  blade  of  a  tenotomy  knife 
should  be  one  inch  long,  its  shank  one  and  three-quarters, 

1  Orthopedic  Surgery  and  Diseases  of  the  Joints.  New  York,  1876,  p.  27.  ' 


234  OPERATIVE  SURGERY. 

its  handle  strong  and  marked  in  such  a  way  that  the  sur- 
geon can  see  at  a  glance  in  which  direction  the  edge  of  the 
blade  is  turned.  The  blade  may  be  straight  or  curved,  it 
should  be  thick  at  the  heel,  very  narrow,  and  the  point 
should  be  somewhat  rounded  and  sharpened  from  side  to 
side  like  a  wedge  or  chisel. 

A  fold  of  skin  should  be  pinched  up  at  the  side  of  the  ten- 
don, and  the  knife  entered  at  its  base,  so  that  a  continuous 
track  will  not  be  left  on  its  withdrawal.  A  preliminary  punc- 
ture may  be  made  with  a  sharp-pointed  knife  or  lancet  to 
facilitate  the  entry  of  the  tenotome. 

The  knife  must  be  entered  "  on  the  flat "  and  passed  either 
under  the  tendon  or  betweeu  it  and  the  skin ;  its  edge  is 
then  turned  toward  the  tendon  and  the  division  effected 
with  gentle  sawing  movements,  the  thumb  being  pressed 
firmly  against  the  tendon  if  the  knife  has  been  passed 
under  it. 

During  the  entry  of  the  knife  and  the  division  of  the 
tendon  the  latter  must  be  kept  firmly  upon  the  stretch, 
and  as  soon  as  the  division  is  complete  the  knife  must  be 
turned  upon  its  side  and  withdrawn,  while  the  surgeon 
follows  its  point  with  his  thumb  or  finger  so  as  to  force 
out  any  blood  that  may  be  in  its  track  and  to  prevent  the 
entrance  of  air. 

Seal  the  wound  with  plaster  or  collodion,  and  then  bring 
the  member  into  the  desired  position. 

lendo  Achillis.  The  knife  should  be  entered  on  the  inner 
side  of  the  tendon  near  its  border,  about  one  inch  above 
the  upper  surface  of  the  calcaueura.  In  this  way  the  pos- 
terior tibial  artery,  which  lies  between  the  tendon  and  the 
inner  malleolus  and  below  the  deep  fascia,  is  secured  from 
injury.  The  heel  must  be  depressed  as  much  as  possible, 
so  as  to  make  the  tendon  more  prominent  and  give  addi- 
tional security  to  the  artery. 

Tibialis  Posticus.  The  tendon  of  this  muscle  may  be 
divided  (A)  above  the  malleolus,  or  (B)  on  the  side  of  the 
foot  just  behind  its  insertion  into  the  scaphoid. 


NEUROTOMY  AND  TENOTOMY.  235 

A.  Above  the  Malleolus.  The  muscle  is  made  tense  by 
everting  the  foot ;  the  knife  is  entered  at  the  inner  side  of 
the  tendon  and  passed  behind  it. 

B.  On  the  Side  of  the  Foot.  Same  position  given  to  the 
foot.  The  knife  should  be  directed  from  above  downward, 
and  passed  under  the  upper  border  of  the  tendon  at  a  point 
half  an  inch  below  and  in  front  of  the  tip  of  the  malleolus. 
Bell1  prefers  to  cut  toward  the  bone. 

Tibialis  Anticus.  Can  be  easily  made  prominent  and 
isolated. 

Peronei.  May  be  divided  at  the  posterior  face  of  the 
lower  end  of  the  fibula,  or  on  the  side  of  the  foot  below  and 
in  front  of  the  tip  of  the  outer  malleolus. 

Flexor  Tendons  at  the  Knees.  It  must  be  remembered 
that  the  external  popliteal  nerve  accompanies  the  tendon 
of  the  biceps  closely,  lying  upon  its  inner  side. 

Sterno-cleido-mastoid.  The  danger  to  be  avoided  in  this 
operation  is  that  of  injury  to  the  external  jugular  vein  at 
the  outer  border  of  the  muscle,  or  to  the  anterior  jugular 
vein  at  its  inner  border.  The  first  can  usually  be  seen 
under  the  skin  and  avoided,  the  other  leaves  the  muscle 
about  three-quarters  of  an  inch  above  the  sternum  and 
passes  backward.  The  muscle  should  be  divided  about 
half  an  inch  above  the  top  of  the  sternum,  and  most  au- 
thorities agree  in  preferring  to  divide  from  before  back- 
ward. The  knife  should  be  entered  at  the  outer  border  of 
the  muscle. 

Levator  Palpebrce.  In  a  case  of  paralysis  of  the  orbi- 
cularis palpebrarum  followed  by  retraction  of  the  levator 
palpebr?e  with  inability  to  close  the  eye,  and  subsequent 
ulceration  of  the  cornea,  Professor  Detmold  divided  the 
latter  muscle  at  its  attachment  to  the  upper  edge  of  the  tar- 
sal cartilage.     The  result  was  very  good. 

1  Manual  of  Surgical  Operations,  3d  edition,  p.  288. 


236 


OPERATIVE  SURGERY. 


TENORRHAPHY. 

Primary.  Performed  immediately  after  the  injury. 
Antiseptic  precautions  are  especially  necessary.  The  distal 
end  of  the  tendon  can  usually  be  recognized  in  the  wound 
without  difficulty.  The  proximal  end  will  sometimes  re- 
tract several  inches,  especially  if  it  was  on  the  stretch  at  the 
time  of  the  injury,  and  an  extensive  dissection  and  splitting 
of  the  sheath  may  be  necessary  to  briug  it  within  reach. 
The  divided  tendon  ends  are  drawn  into  apposition  and 

Fig.  86. 


Tenorrhaphy  by  a  suture  passed  through  the  substance  01  each  segment. 


stitched  together  with  fine  silk,  silkworm-gut,  or  catgut. 
The  common  forms  of  suture  are  represented  in  Figs.  86, 
87,  88,  89. 

If  the  divided  surfaces  cannot  be  brought  into  apposition 
and  kept  there  without  undue  tension,  one  or  both  ends  of 

Fig.  87. 


Tenorrhaphy.    The  tendon  ends  cut  obliquely  to  increase  the  surfaces  in  contact. 

the  tendon  may  be  split  and  turned  down  to  lengthen  it  as 
indicated  in  Fig.  90,  or  the  cut  ends  of  the  tendon  sheath 
may  be  carefully  sutured  in  hopes  that  union  of  the  tendon 


NEUROTOMY  AND  TENOTOMY. 


237 


within  may  occur  as  after  tenotomy  performed  by  the  sur- 
geon. Another  method  is  to  draw  the  cut  ends  of  the 
tendon  together  as  much  as  possible  by  one  or  two  catgut 
sutures,  which  are  left  in  the  gap  to  act  as  a  nidus  for  new 


Tenorrhaphy.    Showing  the  method  of  inserting  a  suture  which  does  not  readily 

pull  out. 

tendon  tissues.  Ingrafting  of  portions  of  tendon  taken 
from  another  regiou  or  even  another  animal  has  been  per- 
formed, aud  it  is  said  successfully.  (Bulletin  de  la  Soc.  de 
Chir.,  1886,  p.  357.) 

Fig.  89. 


A  B 

Tenorrhaphy  by  four  ligatures  inserted  and  tied  (.4)  in  each  stump,  and  their  free 
ends  then  UDited  (B). 

In  all  cases  of  tenorrhaphy  the  tendon  sheath  when  it 
exists  must  be  preserved  as  far  as  possible.  It  is  impor- 
tant to  immobilize  the  limb  during  healing  in  the  position 
of  greatest  relaxation  of  the  sutured  tendon. 


Secondary.     Performed  after  a  considerable  interval  of 
time  has  elapsed  since   the  injury.     The  divided   tendon 

11* 


238  OPERATIVE  SURGERY. 

ends  will  have  to  be  sought  for  in  a  mass  of  cicatricial 
tissue  and  brought  into  the  best  possible  apposition.  The 
ends  can  be  split  and  lengthened  as  already  described ;  if 

Fig.  90. 


Tenorrhaphy  by  flaps  to  bridge  over  a  gap  between  the  tendon  ends. 

this  will  not  do  or  the  proximal  end  of  the  tendon  cannot 
be  found  the  distal  end  may  be  sutured  to  a  neighboring 
tendon  having  the  same  general  anatomical  course. 

The  surface  from   which  union  is  expected  should  be 
freshened  by  scraping. 


MISCELLANEOUS  OPERATIONS. 

Thiersch's  skin  grafting. 

The  wound  to  which  the  graft  is  to  be  applied  must  be 
fresh,  clean,  dry,  and  perfectly  aseptic.  If  it  is  already  a 
granulating  surface  all  pus  must  be  carefully  washed  away 
with  a  sterilized  brush,  soap  and  water,  and  the  granula- 
tions freely  shaved  away  with  a  knife.  It  is  then  thor- 
oughly washed  with  a  sterilized  salt  solution  (about  5j  of 
common  salt  to  Oj  of  water).  Bleeding  is  checked  by  the 
pressure  of  a  sterilized  compress  maintained  until  the  grafts 
are  ready  to  be  applied,  in  order  to  preserve  the  asepsis  and 
to  prevent  the  formation  of  clots  of  blood  which  would 
separate  the  graft  from  contact  with  the  raw  surface. 

The  graft  is  commonly  taken  from  the  front  or  outer 
surface  of  the  thigh,  as  this  presents  a  conveniently  broad 
surface  of  skin  of  the  requisite  thickness.  It  must  be  pre- 
viously shaved  and  scrubbed,  then  rinsed  off  with  alcohol 


NEUROTOMY  AND  TENOTOMY.  239 

and  finally  with  sterilized  water.  The  skin  of  the  thigh  is 
drawn  tense  and  flat  by  one  hand  graspiug  the  thigh  just 
above  the  knee  and  pulling  down.  With  the  other  hand  a 
broad-bladed  razor,  ground  flat  on  the  surface  held  next 
the  thigh,  is  drawn  downward  toward  the  knee  by  quick 
sawing  motions  through  the  skin  parallel  to  and  just  be- 
neath its  surface.  The  cutting  must  be  done  with  accuracy 
and  the  razor's  edge  must  lie  always  in  the  papillary  layer 
of  the  skin.  Practically  it  must  pass  just  deep  enough  to 
have  the  cut  surface  studded  with  minute  specks  of  blood 
which  do  not  coalesce  for  an  appreciable  length  of  time. 
If  the  knife  exposes  any  particle  of  the  subcutaneous  fat 
the  corresponding  part  of  the  intended  graft  must  be  re- 
jected. The  sterilized  salt  solution  already  mentioned  is 
allowed  to  trickle  on  the  skin  immediately  in  front  of  the 
advancing  razor-edge,  and  serves  to  float  the  graft  up  into 
the  concavity  on  the  anterior  surface  of  the  razor,  and 
with  a  little  practice  facilitates  the  cutting.  A  strip  six  or 
eight  inches  long  and  one  and  a  half  or  two  inches  wide 
can  be  cut  and  retaiued  on  a  broad  blade.  The  attached 
end  of  the  graft  is  severed  with  scissors.  The  graft  is 
then  immediately  unfolded  on  the  prepared  wound  surface 
by  retaining  the  whole  width  of  the  free  end  against  one 
margin  of  the  area  to  be  covered,  and  gently  withdrawing 
the  razor  while  its  edge  is  kept  constantly  in  contact  with 
the  wound  surface. 

If  any  portions  of  the  graft  get  turned  over  so  as  to  op- 
pose the  epidermic  layer  to  the  wound  surface,  they  must 
be  carefully  unfolded.  In  addition  all  air-bubbles  must 
be  pressed  out  toward  the  edges ;  and,  in  short,  every  part 
of  the  freshly  cut  papillary  layer  of  the  graft  must  be 
brought  into  accurate  contact  with  the  underlying  raw  sur- 
face which  is  to  be  covered. 

Successive  grafts  are  cut  and  applied  until  the  entire 
surface  is  covered. 

The  grafts  are  then  covered  completely  with  strips  of 
sterilized  rubber  tissue  about  an  inch  wide  (after  rinsing 
them  in  the  sterilized  salt  solution),  placed  side  by  side 
with  the  edges  slightly  overlapping. 

This  arrangement  permits  drainage  and  allows  the  graft 
to  be  kept  damp  with  the  next  applied  sterilized  com- 


240 


OPERATIVE  SURGERY. 


presses,  wrung  out  in  either  the  sterilized  salt  solution  or  a 
sterilized  saturated  solution  of  boric  acid. 

The  compresses  are  covered  with  a  sheet  of  sterilized 
rubber  tissue  to  prevent  drying.  This  dressing  must  be 
very  carefully  bandaged  in  place  with  even  pressure  and 
without  disturbing  the  grafts.  From  time  to  time,  till  it  is 
removed  at  the  end  of  five  days,  it  must  be  moistened  with 
the  sterilized  salt  or  boric  solution. 


ERECTILE   TUMORS. 

The  usual  methods  of  treating  erectile  tumors  are  by  the 
ligature,  caustic,  cautery,  coagulating  injections,  electrolysis, 

Fig.  91. 


Subcutaneous  ligature  of  ncevus. 


and  excision.     Physick  cured  one  upon  the  ringer  by  cir- 
cumscribing it  with  a  deep  incision. 

Ligatures  should  be  so  applied  as  to  cut  off  the  supply 
of  blood  entirely.  Figs.  91,  92,  93,  94,  and  95  represent 
good  methods.  The  caustic  treatment  is  applied  to  small 
najvi ;  nitric  acid,  or  the  acid  nitrate  of  mercury,  may  be 
used.  The  actual  cautery  is  applied  by  passing  white-hot 
needles  into  or  through  the  tumor;  sometimes  a  very  dis- 


NEUROTOMY  AND  TENOTOMY. 


211 


figuring  scar  results.     Coagulating  injections  usually  give 
good  results,  but  the  method  is  considered  dangerous  on 


Fig.  92. 


Subcutaneous  ligature  of  nsevus.     The  needle  passed  under  the  tumor;  one 
thread  divided. 

account  of  the  possibility  that  the  coagulation  may  extend 
into  the  larger  vessels,  and  give  rise  to  embolism.     The 


Fig.  93. 


Fig.  94. 


The  other  end  of  the  divided  thread 
passed  into  the  needle's  eye,  and  the 
needle  passed  through  at  right  angles  to 
its  former  direction. 


The  needle  removed  and  the  nsevus 
strangulated  in  quarters. 


solution,  persulphate  of  iron,  should  be  injected,  three  or 
four  drops  at  a  time,  at  several  points  by  means  of  a  hypo- 
dermic syringe;  or  the  nsevus  maybe  incised  longitudi- 
nally and  the  iron  applied  directly  to  the  surface  of  section. 
If  not  too  extensive  the  whole  nsevus  should  be  dissected 
out  and  the  hemorrhage  controlled  by  pressure,  ligation,  or 
the  actual  cautery.  The  resulting  gap  is  closed  by  a  plas- 
tic operation  or  by  Thiersch  grafts.  Electrolysis  is  applic- 
able to  a  capillary  nsevus  or  birth-mark.     The  poles  of  a 


242 


OPERATIVE  SURGERY, 


battery  are  connected  with  a  pair  of  fine  platinum  needles, 
which  are  plunged  into  the  growth  about  a  quarter  of  an 


Fig.  95. 


Ligature  of  large  neevus.    The  white  loops  are  divided  on  one  side  and  the  black 
on  the  other,  and  the  corresponding  ends  A  A'  and  B  B'  tied  together. 

inch  apart,  and  a  current  of  from  2  to  10  milliamperes  thus 
passed.  The  punctures  must  be  repeated  all  over  the  dis- 
eased area. 

BIRTH-MARK. 


Balmanno  Squire1  has  introduced  a  very  simple  method 
of  removing  "  Port- wine  birth-marks."  He  freezes  the  spot 
with  the  ether  spray  and  makes  a  number  of  fine  parallel 
incisions  from  one-thirty-second  to  one-sixteenth  of  an  inch 
apart,  and  extending  about  half  through  the  skin,  or  at  most 
to  the  depth  of  one-sixteenth  of  an  inch.  A  piece  of  steril- 
ized blotting  paper  is  then  laid  over  the  incision  and  pressed 
steadily  down  upon  the  skin  for  five  minutes,  with  just 
enough  force  not  to  cause  the  incision  to  gape.  In  twenty 
or  thirty  minutes  the  blotting  paper  must  be  thoroughly 
wet  with  a  1:.0000  solution  of  bichloride  of  mercury  and 
removed   by  pulling  it  in  the  direction   of  the  cuts;  the 

i  Essays  on  the  Treatment  of  Skin  Diseases,  No.  III.    London,  1X7<>. 


NEUROTOMY  AND  TENOTOMY. 


243 


underlying  thin  film  of  blood  clot  must  also  be  gently  and 
patiently  washed  off  with  a  camel's-hair  brush.  If  this  is 
properly  done  no  bleeding  will  occur  and  no  scar  will  be 
left,  while  if  the  clot  is  not  removed  it  is  likely  to  cause 
suppuration  and  prevent  primary  union.  In  some  cases  it 
is  necessary  to  make  cross-markings  at  right  angles  to  the 
first  to  eifect  a  complete  cure. 


SEPARATION   OF   WEB-FINGERS. 

Experience  has  shown  that  simple  division  of  the  mem- 
brane uniting  the  two  fingers  is  insufficient,  because  reunion, 
beginning  at  the  angle,  is  certain  to  extend  over  the  whole 
length  of  the  incision.  A  simple  way  of  overcoming  this 
difficulty  is  to  pass  a  leaden  or  silver  wire  through  a  punc- 
ture made  at  the  interdigital  angle,  keep  it  there  until  cica- 
trization has  taken  place  around  it,  as  around  an  ear-ring, 
and  then  divide  the  membrane.  The  angle  being  already 
cicatrized,  the  lateral  wounds  heal  separately. 

Fig.  96. 


Web  fingers. 


Another  plan  is  to  mark  out  a  palmar  and  a  dorsal  trian- 
gular flap  at  the  interdigital  angle,  its  apex  turned  toward 
the  ends  of  the  fingers  (Fig.  96,  A),  then  to  split  the  re- 
mainder of  the  membrane  longitudinally,  pare  off  the  ends 
of  the  triangular  flaps,  and  unite  them  in  the  interdigital 


244  OPERATIVE  SURGERY. 

angle.     By  this  means  a  bridge  of  integument  is  formed 
which  prevents  reunion  of  the  sides. 

These  two  methods  answer  very  well  when  there  is  a  dis- 
tinct interdigital  membrane,  but  some  other  is  required 
when  the  fingers  are  closely  approximated.  The  one  which 
yields  the  best  results  is  represented  in  Fig.  96,  B,  and  Fig. 

Fig.  97. 


97.  A  rectangular  flap  is  dissected  up  from  the  dorsum  of 
one  finger,  and  a  similar  flap  from  the  palmar  surface  of 
the  other  finger,  each  being  left  adherent  by  its  long  side. 
The  fingers  are  then  separated  and  each  flap  turned  in  to 
cover  one  of  the  raw  surfaces. 


CICATEICIAL   FLEXION   OF   THE   PHALANGES. 

The  cicatrix  must  be  divided  thoroughly  to  allow  com- 
plete extension,  and  then  if  skin  flaps  can  be  obtained  from 
the  sides  they  may  be  turned  in  to  cover  the  palmar  surface 
opposite  the  joints.  In  dissecting  up  the  flaps  care  must 
be  taken  not  to  go  deeply  enough  to  involve  the  artery 
which  runs  along  the  side,  otherwise  the  ends  of  the  finger 
may  slough. 

Instead  of  small  lateral  flaps  for  the  flexures  of  the  joints 
the  skin  covering  the  sides  of  the  finger  may  be  mobilized 
by  lateral  or  dorsal  longitudinal  incisions  and  brought  to- 
gether in  the  median  line  of  the  palmar  surface,  the  gaps 
created  on  the  sides  by  their  removal  being  left  to  heal  by 
granulation. 


NEUROTOMY  AND  TENOTOMY. 


245 


dupuytren's  contraction  of  the  fingers. 

Open  Method.  A.  A  simple  transverse  incision  is  made 
through  the  skin  and  palmar  fascia  wherever  the  band  is 
most  prominent,  and  the  gap  covered  with  a  Thiersch  skin 
graft. 

B.  A  longitudinal  incision  is  made  through  the  skin  over 
the  most  prominent  portion  of  the  constricting  band,  and 
crossed  at  each  end  by  a  transverse  incision.  The  flaps 
thus  marked  out  are  dissected  up  from  the  aponeurosis, 
which  is  then  divided  transversely  or  excised. 

Eesultant  gaps  in  the  skiu  should  be  closed  by  flaps  or 
skin  grafts. 

INGROWN   TOENAIL. 

The  base  of  the  toe  is  constricted  with  a  rubber  tourni- 
quet and  a  few  minims  of  a  2  per  cent,  solution  of  cocaine  in- 
jected on  the  sides  and  dorsum.  The  nail  is  then  torn  out 
(in  all  cases)  with  forceps,  one  blade  of  which  is  pushed  up 
under  it  to  free  it  from  the  matrix. 


Fig.  98. 


Ingrown  toenail. 

A.  A,  B,  D,  C,  flap  operation  (parts  removed  shown  in  B.  A',  B',  C,  D'). 

B.  R,D',  S,  wedge  operation— M',  N',  sho-ving  part  removed  by  Cotting's  opera- 
tion. 

I.  A  rectangular  flap,  D,  E,  F,  B  (Fig  98,  A),  about 
one-quarter  of  an  inch  square,  is  made  and  the  skin  con- 


246 


OPERATIVE  SURGERY. 


tained  in  it  reflected.  The  strip  of  matrix  underlying  it 
(Fig.  98  A,  A,  B,  D,  C),  and  the  corresponding-  part  of  the 
nail  in  front,  is  then  thoroughly  dissected  off,  care  being 
taken  to  carry  the  dissection  eutirely  beyond  the  base  and 
side.  The  flap  is  next  replaced  and  secured  and  a  light  dry 
dressing  applied. 

II.  The  exuberant  tissue  and  adjoining  skin  is  pared  off 
close  up  to  the  margin  of  the  nail  and  matrix  (M7,  N'). 
The  resulting  wound  is  left  to  close  by  granulation. 
(Cotting).    (Fig.  98  B,  M',  W  and  Fig.  99  A,  M,  N.) 

III.  In  certain  cases  a  wedge-shaped  piece  can  be  ex- 
cised from  the  side  of  the  toe,  and  by  closing  this  gap  with 
sutures  the  irritated  part  is  drawn  away  from  the  nail. 
(R,  S,  D',  Fig.  98  B). 


Fig.  99. 


A.  X,  Y,  Auger's  method.    M,  N,  Cotting's  method. 

B.  X',  Y',  Anger's  method  (viewed  from  underneath). 

IV.  Anger's  Method.1  With  every  antiseptic  precaution 
the  nail  is  split  longitudinally  in  the  middle  and  the  half 
on  the  diseased  side  torn  out.  A  knife  is  then  made  to 
transfix  the  toe  vertically  from  beneath  the  overhanging 
fold  of  skin  at  the  posterior  angle  of  the  exposed  matrix, 
and  is  carried  straight  forward  along  the  side  of  the  pha- 
lanx through  all  the  tissues,  closely  following  the  lateral 
border  of  the  matrix. 


i  Bull,  et  Mem.  'lit  laSoC.  do  Chir.  <le  1'uris,  1889,  p.  594. 
cal  Record,  September  2,  1898,  i>.  289. 


Also  New  York  Medi- 


NEUROTOMY  AND  TENOTOMY.  247 

The  flap  is  turned  back  and  the  exposed  granulation  and 
epidermic  tissue  is  ablated,  and  the  uncovered  matrix  very 
thoroughly  excised  up  to  the  split  edge  of  the  nail.  The 
flap  is  then  replaced  and  sutured,  and  the  wound  dressed 
antiseptically. 


THE     OPERATIVE     TREATMENT     OF     DISEASED    CERVICAL 
GLANDS. 

The  operations  required  in  the  treatment  of  diseased  cer- 
vical glands  comprise  opening  abscesses,  scraping  and  slit- 
ting up  sinuses,  and  partial  or  complete  removal  of  the 
enlarged  lymph  nodes.  When  the  latter  have  not  become 
broken  down  aud  matted  together  into  an  indistinct  mass 
by  inflammatory  processes — in  other  words,  when  the  glands 
can  be  felt  as  rounded,  more  or  less  movable  tumors,  each 
will  be  found  enclosed  in  a  distinct  capsule,  which,  if  once 
opened,  permits  of  the  gland  being  readily  "shelled  out" 
with  a  Yolkmann  spoon.  There  remains  only  a  small 
pedicle  of  vessels  to  be  secured  at  the  base  of  the  node. 

Removal  is  ordinarily  accomplished  through  a  more  or 
less  longitudinal  incision  which  follows  the  general  direc- 
tion of  the  underlying  structures,  and  is  placed  over  the 
most  prominent  part  of  the  tumefaction.  This  is  gener- 
ally along  the  anterior  or  posterior  border  of  the  sterno- 
mastoid  muscle ;  occasionally  it  may  be  necessary  to  make 
it  along  nearly  the  whole  length  of  both  borders  to  obtain 
sufficiently  free  access  to  all  the  glands.  The  incision  must 
be  long  enough  to  give  a  clear  view  of  each  structure  as  it 
is  encountered,  and  to  permit  of  ready  control  of  the  hemor- 
rhage. 

The  difficulties  attending  a  thorough  removal  of  all  dis- 
eased parts  by  even  a  double  longitudinal  incision  are  so 
great  that  Dr.  Hartley,  of  New  York,1  has  devised  an 
operation  in  which  cutaneous  flaps  are  raised  from  the  sur- 
face of  the  tumor.  At  first  sight  it  appears  unnecessarily 
severe,  but  the  results  hitherto  have  been  excellent,  and  the 
scarring  is  not  so  noticeable  as  to  offset  the  great  advan- 

1  This  description  has  been  revised  by  Dr.  Hartley,  wbo  expects  to  publish  bis 
method  with  a  report  of  cases, 


248 


OPERATIVE  SURGERY. 


tages  gained  by  a  complete  exposure  of  all  the  important 
parts  which  are  in  close  relationship  with  the  enlarged 
glands. 

The  incision  is  S-shaped  (Fig.  100,  B,  C,  D),  and  involves 
only  the  skin,  subcutaneous  tissue,  aud  fascia  ;  starting  below 
the  chin  it  passes  in  a  curve  downward  and  backward  to 


Fig.  100. 


B,  C,  D,  Hartley's  incision  for  the  removal  of  enlarged  cervical  glands. 
A.  Point  where  the  sterno-mastoid  is  divided. 


the  hyoid  bone,  then  np  behind  the  angle  of  the  jaw  to  near 
the  lobule  of  the  ear,  whence  it  sweeps  down  along  the  an- 
terior border  of  the  trapezius,  forward  over  the  sterno- 
mastoid,  and  downward  and  backward  again  to  terminate 
above  the  middle  of  the  clavicle.  (Fig.  100).  The  flaps 
thus  formed  are  dissected  up,  exposing  nearly  the  whole 
length  of  the  sterno-mastoid,  and  the  latter  cut  transversely 
near  its  centre  and  the  ends  reflected,  care  being  taken  not 
to  injure  the  spinal  accessory  nerve  above.  The  point 
where  the  muscle  is  divided  must  not  be  in  the  line  of  the 


NEUROTOMY  AND  TENOTOMY.  249 

cutaneous  incision,  but  under  the  middle  of  one  of  the 
flaps,  preferably  the  upper.  (Fig.  100,  A).  The  great  ves- 
sels are  thus  exposed  from  the  mastoid  process  to  the  cla- 
vicle, and  the  operator  can  excise  the  adherent  and  diseased 
glands  and  avoid  injury  to  the  adjacent  important  struc- 
tures. 

At  the  close  of  the  operation  the  divided  ends  of  the 
sterno-mastoid  are  united  with  catgut,  the  flaps  replaced  and 
loosely  sutured  in  position,  and  drainage  provided  for  in 
the  most  dependent  angles. 

This  large  incision  is  only  used  when  the  glands  in  the 
superior  and  inferior  carotid  and  submaxillary  triangles 
are  involved  simultaneously.  For  less  extensive  disease 
the  upper  or  lower  flap  may  be  employed  alone,  or  one  may 
be  fashioned  with  a  pedicle  in  a  position  the  reverse  of  that 
shown  in  the  figure.  The  incision  for  a  single  flap  should 
approximately  correspond  to  the  circumference  of  the  tumor, 
which  is  then  exposed  in  its  entirety  by  division  of  the 
sterno-mastoid  below  the  joint  where  it  is  entered  by  the 
spinal  accessory  nerve.  The  flap  consists  of  skin,  subcu- 
taneous tissue,  platysma,  and  fascia,  and  after  reflecting  it 
the  muscle  is  always  cut  beneath  the  centre  of  the  flap,  and 
not  in  the  line  of  the  cutaneous  incision. 

OSTEOTOMY. 

Osteotomy  of  the  Femur — 

I.  Through  the  Neck  (Adams's  operation),  described  on 
page  151. 

II.  Below  the  Great  Trochanter  (Gant's  operation),  de- 
scribed on  page  151. 

III.  Osteotomy  of  the  Shaft  of  the  Femur. 

In  a  normal  femur  the  epiphyseal  line  is  about  on  a  level 
with  the  tubercle  of  the  adductor  magnus  and  horizontal  in 
direction.  But  in  cases  of  genu  valgum  it  is  oblique  and 
parallel  with  the  articular  surface.  This  is  due  to  the  fact 
that  geuu  valgum  is  produced  by  an  overgrowth  of  the  dia- 
physis  of  the  femur  and  not  of  the  epiphysis  (Fig.  101). 

Osteotomy  of  the  Shaft  of  the  Femur  from  the  Outer  Side. 
The  knee  is  partially  flexed  and  supported  on  a  sand-bag 


250 


OPERATIVE  SURGERY 


beneath  its  inner  surface.  A  longitudinal  incision  down 
to  the  bone  is  made  on  the  outer  aspect  of  the  thigh  about 
two  inches  above  the  top  of  the  external  condyle  and  in 
front  of  the  tendon  of  the  biceps.  The  osteotome  is  intro- 
duced, is  turned  at  right  angles  to  the  long  axis  of  the 
femur,  and  is  driven  with  short  strokes  of  the  mallet  at 

Fig.  101. 

.,■■*« . 

■'■•'■  ■  ' 


fefgL1 

/i'i*li  J."  ■)  \  ''•  ,■".  J  ■  '.I  -'  \ 


Vertical  section  through  the  lower  end  of  the  femur  in  a  case  of  severe 

genu  valgum. 
Epiphyseal  line.    B.  Transverse  line  drawn  through  the  adductor  tubercle. 
C.  Line  of  bone  section  in  Macewen's  operation. 


least  two-thirds  th rough  the  bone,  or  far  enough  to  render 
it  easy  for  the  operator  to  complete  the  division  of  the  bone 
by  fracturing  it.  This  must  be  done  cautiously,  to  avoid 
splintering,  by  first  freely  extending  the  knee  and  then  ad- 
ducting  the  leg,  while  counter  pressure  is  made  against  the 
inner  surface  of  the  thigh  ;  after  each  stroke  of  the  mallet 
the  chisel  is  loosened  but  not  withdrawn.  At  the  conclu- 
sion of  the  operation  the  wound  is  closed  and  dressed  anti- 
septically,  and  the  limb  is  immobilized  in  the  corrected — 
straight — position. 

Macewen's  Supra-condyloid  Osteotomy  of  the  Femur.    The 
hip  and  knee  are  flexed,  and  the  thigh  supported  on  its 


NEUROTOMY  AND  TENOTOMY.  251 

outer  side.  A  longitudinal  incision  about  one  inch  long  is 
carried  down  to  the  bone  on  the  inner  surface  of  the  thigh. 
It  should  be  one-half  an  inch  anterior  to  the  tendon  of  the 
adductor  magnus,  and  with  its  centre  on  a  line  drawn  trans- 
versely a  finger's  breadth  above  the  top  of  the  external 
condyle. 

Before  the  knife  is  withdrawn  the  osteotome  is  slipped  in 
by  its  side  until  it  touches  the  bone.  Its  cutting  edge  is 
then  turned  at  right  angles  to  the  long  axis  of  the  thigh, 
but  without  using  pressure  enough  to  tear  off  the  perios- 
teum, with  which  it  is  kept  in  contact.  The  edge  is  passed 
over  the  inner  surface  of  the  bone  until  it  reaches  the  pos- 
terior internal  border,  and  is  then  driven  from  behind  for- 
ward and  toward  the  outer  side.  The  internal  surface  is 
next  divided,  and  after  this  the  chisel  is  directed  from  be- 
fore backward  aud  toward  the  outer  posterior  angle  of  the 
femur.  This  definite  order  of  procedure  leaves  the  opera- 
tor certain  of  what  has  been  divided  and  what  is  still  to  be 
done.  The  osteotome  is  not  withdrawn  till  all  the  bone 
has  been  cut  through  except  a  thin  shell  on  the  outer  sur- 
face of  the  femur.  This  is  snapped  or  bent  by  adducting 
the  leg,  while  counter  pressure  is  made  with  the  hand  at  the 
point  of  incision.  The  wound  needs  no  sutures  or  drain- 
age, and  is  simply  dressed  antiseptically  and  immobilized 
in  the  straight  position. 

IV.  Ogston's  Operation  (division  of  the  internal  condyle). 
The  point  of  a  narrow-bladed  knife  is  entered  in  the  centre 
of  the  inner  surface  of  the  thigh  about  two  inches  above 
the  adductor  tubercle.  With  the  edge  directed  toward  the 
bone  it  is  passed  downward  and  outward  over  the  inner 
and  anterior  surface  of  the  femur  till  the  groove  between 
the  front  of  the  condyles  is  reached,  and  the  joint  opened. 
The  cutaneous  opening  on  the  inner  surface  of  the  thigh  is 
made  large  enough  to  admit  a  fine  saw,  and  the  junction  of 
the  internal  condyle  with  the  femur  is  sawn  through  ob- 
liquely. Many  surgeons  now  prefer  to  use  the  chisel  instead 
of  the  saw. 

By  adducting  the  leg  the  loosened  condyle  is  displaced 
upward  on  the  femur,  and  the  genu  valgum  thus  cor- 
rected. 


252 


OPERATIVE  SURGERY. 


This  operation  has  been  largely  superseded  by  transverse 
division  of  the  shaft  above  the  condyles. 


Fig.  102. 


Fig.  103. 


Genu  valgum. 


Genu  valgum. 


OSTEOTOMY   FOR   BENT   TIBIA. 

A  longitudinal  incision  is  carried  down  to  the  bone  over 
its  inner  surface  at  the  point  where  the  abnormal  curvature 
is  most  marked.  At  this  point  the  bone  is  chiselled 
through  transversely,  partially  or  completely. 

The  fibula  usually  does  not  need  division.  The  opera- 
tion is  completed  by  forcibly  straightening  the  leg.  In  ex- 
treme cases  a  wedge-shaped  piece  of  bone  may  have  to  be 
removed.  Its  base  will  usually  correspond  to  the  crest  of 
the  tibia. 


OSTEOTOMY    FOR    HALLUX    VALGUS. 


A  longitudinal  incision  about  half  an  inch  in  extent  is 
carried  down  to  the  periosteum  on  the  inner  surface  of  the 
first  metatarsal  bone.  It  should  be  placed  so  that  a  narrow- 
bladed  osteotome  can  divide  transversely  the  shaft  of  the 
bone  just  posterior  to  the  enlarged  digital  extremity. 


NEUROTOMY  AND  TENOTOMY.  253 

The  toe  is  then  forcibly  brought  inward  into  line  with 
its  metatarsal  bone.  But  this  simple  division  of  the  bone 
will  rarely  be  found  sufficieut.  It  is  more  often  necessary 
to  remove  about  a  quarter  of  an  inch  of  the  shaft  at  this 
point.  Then  the  digital  extremity  can  turn  on  the  trans- 
verse metatarsal  ligament  as  a  radius,  and  the  end  of  the  toe 
is  brought  much  further  inward. 

The  operation  of  incision  of  the  metatarso-phalangeal 
joint  for  this  deformity  should  be  condemned. 


CUNEIFORM    OSTEOTOMY    FOR   TALIPES    EQUINO- VARUS. 

A  horizontal  incision  is  made  along  the  outer  side  of  the 
foot  from  about  the  centre  of  the  anterior  portion  of  the 
outer  surface  of  the  os  calcis  across  the  cuboid  to  the  base 
of  the  fifth  metatarsal  bone.  If  necessary  this  is  joined  at 
its  centre  by  a  liberating  incision  passing  perpendicularly 
to  the  horizontal  incision  across  the  outer  surface  and 
dorsum  of  the  foot  to  or  over  the  scaphoid. 

The  base  of  the  wedge  of  bone  to  be  removed  will  con- 
sist mainly  of  the  cuboid  with  portions  of  the  os  calcis,  the 
astragalus,  and  perhaps  a  part  of  the  external  cuneiform 
and  base  of  the  fifth  metatarsal.  The  apex  will  correspond 
to  a  point  on  the  inner  surface  of  the  scaphoid.  The 
amount  of  bone  which  may  need  removal  will  of  course 
depend  upon  the  extent  of  the  deformity,  but  in  extreme 
cases  it  may  include  portions  of  all  the  tarsal  and  some  of 
the  metatarsal  bones.  In  every  case  the  cuboid  will  form 
a  large  proportion  of  the  wedge. 

With  a  blunt  periosteal  elevator  all  the  soft  parts  are  de- 
tached from  the  bone  that  is  to  be  removed  ;  the  peronsei 
tendons  are  retracted  or  protected  ;  a  thin  blunt  elevator 
may  be  pushed  close  under  the  plantar  surface  of  the  bones 
to  protect  the  soft  parts  of  the  sole.  The  chisel  is  then 
driven  in  for  the  first  bone  cut,  generally  at  the  anterior  end 
of  the  outer  surface  of  the  cuboid.  It  is  directed  toward 
the  lower  part  of  the  scaphoid  tubercle.  The  second  line 
of  bony  division  will  usually  need  to  pass  just  behind  the 
anterior  articular  surface  of  the  os  calcis  and  through  the 
neck  of  the  astragalus  to  meet  the  first  incision  at  the  sca- 

12 


254  OPERATIVE  SURGERY. 

phoid  tubercle.  This  wedge  of  bone  is  then  pried  or 
wrenched  out  entire,  while  any  remaining  attachments  be- 
neath are  severed  with  blunt-pointed  scissors  or  a  knife 
kept  close  to  the  bone.  If  then  it  is  found  that  the  foot 
cannot  be  made  to  assume  the  proper  position  without  ten- 
sion another  slice  of  bone  is  chiselled  off,  especially  toward 
the  apex  of  the  wedge.  This  may  be  supplemented  by 
tenotomy  of  any  resisting  tendons.  The  thickened  epider- 
mis and  the  bursa  usually  found  over  the  site  of  the  cuboid 
can  be  excised  if  there  is  found  to  be  a  redundancy  of  skin 
after  straightening  the  foot. 

No  wiring  of  the  bones  is  necessary.  The  soft  parts  are 
sutured  and  the  wound  dressed  antiseptically.  Any  oozing 
which  may  subsequently  occur  will  dry  and  make  of  a 
simple  antiseptic  dressing  a  very  useful  splint. 

Of  the  great  number  of  other  operative  procedures  which 
may  be  used  singly  or  in  combination  with  each  other  or 
with  cuneiform  osteotomy  for  correcting  pes  varus  or  equino- 
varus  mention  should  be  made  of  tenotomy  of  resisting 
tendons  (q.  v.),  extirpation  of  the  astragalus  (q.  v.),  extir- 
pation of  the  cuboid  or  of  several  tarsal  bones  simulta- 
neously, linear  osteotomy  of  the  tibia  and  fibula  just  above 
ankle-joint  (q.  v.),  excision  of  a  portion  of  the  shaft  of  the 
fibula  near  the  base  of  the  external  malleolus,  followed  by 
forcible  abduction  of  the  foot,1  and  Phelps's2  operation. 
The  latter,  although  not  an  osteotomy,  will  be  described 
here.3 

It  is  extensively  used  for  remedying  talipes  equino- varus, 
and  consists  in  a  simple  division  of  all  structures  which  re- 
sist correction  of  the  deformity.  The  tendo  Achillis  is  first 
divided  subcutaneously ;  then,  while  the  foot  is  flexed  dor- 
sally,  abducted  and  everted,  an  incision  through  the  skin  is 
made  from  just  in  front  of  the  internal  malleolus  verti- 
cally downward  across  the  inner  third  of  the  sole  of  the 
foot.  After  making  the  parts  tense  the  tibialis  autieus  and 
posticus,  the  deltoid  ligament,  part  of  the  abductor  pollicis, 
the  plantar  fascia,  and  the  flexor  brevis  and  lougus  digito- 

1  Hopkins  :  Annals  of  Surgery,  April,  1895,  p.  461. 

2  New  England  Medical  Monthly,  ]8'J1. 

1  This  excellent  operation  is  discussed  and  the  results  detailed  in  Transactions 
Am.  Orthopaedic  Asso.,  vol.  vii.  p.  43. 


NEUROTOMY  AND  TENOTOMY.  255 

rum  are  severed  as  encountered  in  the  wound.  The  plantar 
vessels  and  nerves  are  spared  if  possible,  although  their  in- 
ternal branches  have  been  cut  without  bad  effect. 

As  each  structure  is  divided  an  attempt  is  made  to  forci- 
bly place  the  foot  in  its  proper  position.  Phelps  employs 
a  powerful  system  of  levers,  and  ruptures  any  resisting 
ligamentary  or  fibrous  bands.  When  all  opposition  has 
been  properly  overcome  the  anterior  segment  of  the  foot 
can  be  bent  backward  in  overcorrection,  thus  probably 
opening  the  astragalo-scaphoid  and  calcaneo-cuboid  joints. 
Only  in  about  10  per  cent,  of  all  cases,  according  to  the 
originator  of  this  operation,  will  osteotomy  be  required. 
When  necessary  to  correct  the  deformity  after  all  the  re- 
sisting soft  parts  have  been  cut,  the  neck  of  the  astragalus 
should  be  divided  from  the  inside  ;  then,  if  this  is  insuf- 
ficient, a  wedge  may  be  removed  from  the  anterior  por- 
tion of  the  os  calcis  ;  the  base  of  the  wedge  lies  externally, 
the  apex  where  the  neck  of  the  astragalus  has  been  divided. 
The  open  wound  on  the  inner  side  of  the  foot  is  either 
lightly  packed  with  iodoform  gauze  or  allowed  to  heal 
under  a  moist  blood  clot ;  over  this  an  antiseptic  dressing 
is  applied  and  encased  in  plaster  of  Paris,  the  foot  being 
maintained  in  a  slightly  overcorrected  position. 


CUNEIFORM   OSTEOTOMY   FOE   TALIPES   EQUINUS. 

Two  horizontal  incisions  are  employed. 

The  inner  incision  passes  along  the  internal  surface  of 
the  neck  of  the  astragalus  and  across  the  scaphoid  to  ter- 
minate at  the  internal  cuneiform  bone.  The  external  inci- 
sion extends  from  the  middle  of  the  anterior  portion  of  the 
outer  surface  of  the  os  calcis  across  the  cuboid  to  terminate 
at  the  base  of  the  fifth  metatarsal  bone.  The  soft  parts 
are  raised  from  the  dorsum  of  the  foot,  and  a  flat  periosteal 
elevator  can  be  passed  close  beneath  the  plantar  surface  of 
the  bones  to  protect  the  soft  parts  of  the  sole.  A  wedge 
is  then  cut  from  the  tarsal  bones  with  the  base  on  the  dor- 
sum of  the  foot.  Its  extent  will  depend  on  the  degree  of 
the  deformity,  but  the  apex  must  reach  to  the  plantar  sur- 
face of  the  bones.     A  metacarpal  saw  or  chisel  can  be  used. 


256  OPERATIVE  SURGERY. 

The  wedge,  which  may  be  extracted  in  one  piece,  will 
consist  chiefly  of  the  scaphoid  and  cuboid  bones,  with  per- 
haps portions  of  the  anterior  extremities  of  the  astragalus 
and  os  calcis.  At  the  close  of  the  operation  the  soft  parts 
which  have  been  divided  are  sutured  and  the  foot  immobilized 
with  the  bones  in  apposition. 


CUNEIFORM    OSTEOTOMY   FOE  TALIPES  VALGUS. 

An  incision  is  begun  just  below  the  apex  of  the  internal 
malleolus  and  carried  forward  two  inches.  The  soft  parts 
are  carefully  raised  from  the  inner  and  under  surface  of  the 
astragalus  and  a  suitable  wedge  removed  from  it.  The  base 
of  the  wedge  should  lie  below  and  include  either  the  neck 
alone  of  the  astragalus  or  the  articular  surfaces  of  the  astrag- 
alus and  scaphoid. 


OPERATIONS    FOR    UNUNITED    FRACTURE. 

The  aim  of  the  operative  treatment  for  old  ununited 
fracture  is  to  place  the  freshened  ends  of  the  bone  in  con- 
tact and  to  keep  them  immobilized  in  this  position. 

A  free  incision  is  necessary.  In  general  it  should  be  in 
the  long  axis  of  the  limb,  and  so  placed  as  to  reach  the 
point  of  fracture  by  the  shortest  route  with  the  least  pos- 
sible damage  to  nerves  and  vessels.  Any  tissue  which  may 
be  found  intervening  between  the  ends  of  the  bone  is  dis- 
sected out  and  removed.  It  will  often  be  found  advan- 
tageous to  protrude  the  ends  of  the  bone  through  the 
wound.  The  extremity  of  each  fragment  is  then  pared  off 
with  the  rongeur  or  chisel  till  fresh  cancellous  tissue  is  ex- 
posed over  the  whole  section  of  the  shaft.  If,  the  frag- 
ments override,  enough  bone  is  removed  to  allow  the  ends 
to  be  easily  brought  into  apposition.  In  such  cases  the 
exposed  ends  of  the  bones  are  sometimes  dovetailed  into 
each  other  or  sawn  off  in  such  a  manner  as  to  bring  large 
surfaces  in  contact.  Then  nails  or  pegs  are  driven  in  at 
right  angles  to  the  shaft.  If  these  latter  are  employed 
I  here  is  a  great  probability  of  suppuration,  with  more  or 


NEUROTOMY  AND  TENOTOMY.  257 

less  necrosis,  and  they  should  always  be  placed  with  a  view 
to  their  early  subsequent  removal.  Wiring  is  to  be  con- 
demned as  superfluous.  It  will  seldom  be  found  necessary 
to  do  more  than  freshen  the  ends  of  bone  and  maintain 
them  in  quiet  apposition  with  a  suitable  splint.  If  there 
is  the  least  doubt  about  their  remaining  in  this  position 
while  the  spliut  is  applied  and  subsequently,  it  is  better  to 
drill  a  small  hole  about  half  an  inch  from  the  fracture  line 
on  each  side  and  tie  the  ends  together  with  a  piece  of  kan- 
garoo-tendon or  stout  chromicized  catgut.  This  of  course 
has  no  great  strength,  but  if  the  limb  is  haudled  carefully 
it  will  keep  the  bones  in  contact  and  prevent  the  interposi- 
tion of  soft  parts  till  the  limb  has  been  immobilized.  In 
addition  to  this  the  periosteum  is  as  far  as  possible  preserved, 
and  any  divided  soft  parts  in  the  neighborhood  should  be 
placed  in  proper  position  and  reunited.  This  will  serve  as 
a  sling  for  the  bones  to  rest  in.  The  wound  is  then  closed 
layer  by  layer  and  dressed  antiseptically,  with  provision 
for  temporary  drainage.  If  pegs  or  nails  have  been  used 
they  should  reach  to  the  skin  surface  and  be  included  in 
the  dressings. 


SUTURE    OF    THE    PATELLA. 

I.   Open  Method. 

Every  antiseptic  precaution  is  necessary.  A  median 
longitudinal  incision  is  made  about  three  inches  in  extent, 
its  centre  opposite  the  point  of  fracture.  Everything  is 
divided  down  to  the  bone.  Any  bloody  effusion  or  coagu- 
lum  between  the  fragments  is  simply  pressed  out,  and  noth- 
ing is  introduced  into  the  interior  of  the  joint.  Interposed 
fibrous  and  periosteal  shreds  are  cleared  away.  The  bone 
is  drilled  in  the  median  line  on  each  side  of  the  point  of 
fracture.  Both  holes  are  oblique  and  start  on  the  anterior 
surface  of  the  bone  half  an  inch  from  the  edge  of  the  frac- 
ture. They  should  terminate  opposite  each  other  in  the 
fractured  surface  close  to  but  not  including  the  articular 
cartilage. 

The  fresh  surfaces  of  bone  are  then  brought  into  accurate 
contact  by  a  silver  wire  passed  through  the  drill  holes.    The 


258  OPERATIVE  SURGERY. 

wire  is  cut  short  and  the  ends  hammered  into  the  bone  or 
left  to  protrude  from  the  wound,  to  be  subsequently  with- 
drawn. A  better  procedure  is  to  use  silk  or  silkworm-gut 
instead  of  wire.  The  skin  wound  is  then  closed  and  dressed 
antiseptically  and  the  leg  immobilized  by  a  plaster-of-Paris 
splint. 

Fig.  104. 


Mediate  suture  for  fracture  of  the  patella. 

II.  Mediate  Silk  Suture  (Fig.  104). 

This  may  be  done  with  cocaine  anaesthesia,  but  the  chance 
of  infection  is  somewhat  increased  thereby.  A  longitudinal 
median  incision  is  made  extending  well  above  and  below 
the  fragments.  Clots  are  removed  from  the  joiut  and  the 
fibro-periosteal  fringe  lifted  up  if  one  has  been  found.  Then, 
with  a  full-curved  needle,  a  stout  silk  ligature  is  passed 
transversely  through  the  ligamentum  patella?  close  to  the 
apex  of  the  patella,  then  transversely  in  the  opposite  direc- 
tion through  the  tendon  of  the  quadriceps  close  to  its  inser- 
tion, and  then  drawn  tight  and  tied  while  the  fragments 
are  held  together.  The  incision  is  then  closed  without 
drainage. 

Many  other  more  or  less  complicated  methods  of  holding 
the  fragments  together  have  been  devised ;  this  one  seems 
to  be  as  simple  as  any,  and  has  proved  to  be  efficient  and 
safe  in  more  than  fifty  personal  cases. 


OPERATION   FOR   NON-UNrON   AFTER    FRACTURE   OF    THE 
OLECRANON    PROCESS. 

A  median  longitudinal  incision  is  made  over  the  posterior 
surface  of  the  olecranon  and  ulna,  exposing  the  bone  at  the 


NEUROTOMY  AND  TENOTOMY.  259 

point  of  fracture.  The  interposed  fibrous  tissue  is  cleared 
away  and  the  ends  of  the  fragments  freshened.  The  ole- 
cranon and  ulna  are  drilled  obliquely  without  perforating 
the  articular  surface.  The  holes  start  on  the  posterior  sur- 
face about  one-quarter  of  an  inch  from  the  edge  of  the 
fracture  and  terminate  in  the  fractured  surface. 

The  fragments  are  drawn  together  with  a  silk  suture  or 
silver  wire,  as  in  the  patella,  and  the  limb  immobilized  by 
an  antiseptic  dressing  in  complete  extension. 

Mediate  suture,  with  silk  passed  through  the  tendon  of 
the  triceps  and  a  hole  drilled  transversely  through  the  shaft 
of  the  ulna  half  an  inch  or  more  below  the  fracture,  is 
probably  to  be  preferred  to  direct  suturing. 


LAMINECTOMY/ 

An  incision  five  or  six  inches  long  is  made  in  the  median 
line  over  the  summit  of  the  spinous  processes  in  question, 
and  quickly  deepened  close  to  one  side  of  them  till  the 
lamina?  are  exposed,  from  which  the  periosteum  with  the 
attached  muscles  is  raised  with  an  elevator  out  to  the  artic- 
ular and  transverse  processes.  The  bases  of  the  spinous 
processes  are  next  cut  through  with  a  chisel  or  bone  for- 
ceps, and  the  opposite  laminae  freed  in  the  same  way  of 
periosteum  and  muscle,  without  disturbing  the  muscular  at- 
tachments of  the  spinous  processes. 

Some  operators  prefer  to  make  two  parallel  incisions  on 
each  side  of  the  spinous  processes,  which  are  then  excised, 
and  Horsley,  to  better  expose  the  lamina?,  divides  the 
lumbar  aponeurosis  and  muscles  at  right  angles  to  the  mid- 
dle of  the  longitudinal  incisions.  The  sides  of  the  wound 
are  well  retracted  and  the  lamina?  are  divided  close  to  the 
transverse  processes  with  a  rongeur,  bone  forceps,  or  chisel, 
and  the  posterior  arch  thus  removed. 

If  the  trouble  is  not  then  apparent  before  opening  the 
dura  a  probe  should  be  passed  up  and  down  to  make  sure 
that  the  cord  has  been  exposed  in  the  proper  locality.     If, 

1  Thorburn:  Surg,  of  Spin.  Cord.  Lloyd:  Amer.  Journ.  Med.  Sciences,  1891, 
vol.  102,  p.  25. 


260  OPERA TIVE  SURGES, Y. 

then,  it  is  considered  necessary,  the  dura  is  pinched  up  and 
opened  longitudinally  in  the  median  line  behind. 

Subsequently  the  wound  in  the  dura  is  closed  with  fine 
catgut  or  silk  sutures  and  the  overlying  parts  brought 
together  by  buried  and  superficial  sutures  over  a  drainage- 
tube  placed  in  the  deepest  portion  of  the  wound. 


PART  VI. 

PLASTIC   OPERATIONS   ON   THE  FACE. 


Plastic  operations  are  required  for  the  relief  of  congen- 
ital defects  or  for  the  restoration  of  parts  lost  by  disease  or 
injury.  The  methods  most  commonly  employed  are  of  two 
kinds : 

1.  By  Approximation  of  the  Edges.  This  is  applicable 
to  cases  in  which  the  loss  of  tissue  is  not  great  and  the  ad- 
joining parts  are  supple.  The  edges  of  the  gap  are  simply 
pared  and  brought  together.  It  is  sometimes  necessary  to 
make  "  liberating  incisions  "  on  one  or  both  sides  for  the 
relief  of  tension. 

2.  By  Transfer  of  a  Flap.  A  flap  of  suitable  shape  and 
size  is  dissected  up  and  transferred,  by  turning  it  about  its 
base,  to  the  place  where  it  is  needed,  its  vitality  being 
insured  by  the  preservation  of  its  base  or  pedicle.  This 
method  admits  of  a  great  variety  of  modifications  in  its 
details,  from  a  simple  sliding  of  a  skin  flap,  which  differs 
but  slightly  from  the  method  by  approximation,  to  the 
transfer  of  skin,  muscle,  and  bone,  or  the  taking  of  the  flap 
from  another  limb  or  individual. 

The  names  Indian,  Italian,  French,  and  German  methods 
have  been  given  to  the  different  varieties,  but  Verneuil1  has 
pointed  out  the  impropriety  of  continuing  to  employ  them, 
especially  since  at  least  two  of  them,  the  French  and  Ger- 
man, have  their  origin  in  an  oversensitive  patriotism  not 
mindful  enough  of  the  actual  facts.  The  Indian  and  Italian 
methods  were  first  employed  for  the  restoration  of  the  nose; 
in  the  former  a  flap  was  taken  from  the  forehead  and  brought 
down  by  twisting  the  pedicle  which  occupied  the  space  be- 

1  M6moires  de  Chirurgie,  vol.  i.    Chirurgie  RSparatrice,  p.  401. 
12* 


262  OPERATIVE  SURGERY. 

tween  the  eyebrows.  The  term  is  now  applied  to  any  oper- 
ation in  which  the  flap  is  made  with  a  long  pedicle  situated 
at  some  distance  from  the  space  which  the  flap  is  to  cover, 
and  in  which  also  the  flap  is  brought  into  place  by  rotation 
over  a  greater  or  less  arc  described  about  the  base  of  the 
pedicle  as  a  centre  (see  Fig.  133). 

In  the  Italian  method  the  flap  is  taken  from  a  distant 
part  of  the  body,  as  in  restoration  of  the  nose  by  a  flap 
taken  from  the  arm  (Fig.  135).  Tagliacozzi,  of  Bologna, 
the  originator  of  this  method,  allowed  the  flap  to  suppurate 
for  a  few  days,  so  as  to  increase  its  thickness,  before  fas- 
tening it  in  its  new  situation.  Graefe  sought  for  primary 
union,  and  gave,  rather  pompously,  the  name  German  method 
to  this  modification,  ignorant  of  the  fact  that  it  had  been 
suggested  more  than  a  century  before  by  Reneaulme  de  la 
Garanne,  and  unmindful  of  the  other  fact  that  it  contained 
no  new  principle,  and  must  have  been  entertained  by  Tag- 
liacozzi, and  only  rejected  for  the  sake  of  another  advantage 
incompatible  with  it. 

In  the  so-called  French  method,  the  principles  of  which 
are  found  in  Celsus,  the  flap  has  a  broad  base,  and  is  brought 
into  place,  not  by  rotation,  but  by  traction  in  the  direction 
of  its  axis  (Figs.  116  and  128).  The  variations  and  com- 
binations of  these  methods  are  now  so  numerous  that  the 
names  no  longer  have  much  descriptive  value. 

General  Principles.  The  edges  of  the  flaps  must  be 
brought  together  without  tension,  and  united  very  accu- 
rately by  means  of  fine  silk,  catgut,  or  silver  sutures ;  and 
it  is  well  to  cut  the  edges  obliquely  so  as  to  have  a  broader 
surface  of  contact  as  proposed,  I  believe,  by  Dr.  Packard. 

All  hemorrhage  "must  cease  before  the  flaps  are  brought 
into  place.  The  presence  of  a  clot  of  blood  under  a  trans- 
ferred flap  is  one  of  the  most  common  causes  of  failure. 

Flaps  must  be  taken  from  healthy  non-cicatricial  skin,  and 
whenever  the  skin  is  thin  and  not  very  vascular  the  subcu- 
taneous layer  should  be  taken  with  it  to  insure  its  vitality. 

The  base  of  a  flap  should  occupy  the  quarter  from  which 
the  main  supply  of  blood  is  received,  and  the  direction  and 
shape  of  tin.'  nap  should  hi'  such  that  it  can  be  brought  into 
place  with  the  least  amount  of  twisting  of  the  base. 


PLASTIC  OPERATIONS  ON  THE  FACE.  263 

The  flap  should  be  made  considerably  larger  than  the 
space  it  is  to  fill,  and,  to  insure  accuracy,  it  is  well  to  cut 
it  according  to  a  pattern  previously  made  of  paper  or  oil 
silk.  It  is  well  also  to  mark  the  angles  by  fine  pins  plauted 
erect  in  the  skin. 

The  raw  surface  left  by  the  dissection  of  a  flap  may  be 
partly  covered  by  drawing  its  edges  together  with  sutures ; 
the  remainder  must  be  left  to  granulate  or  may  be  covered 
by  Thiersch  grafting.  Dr.  Gurdon  Buck1  recommended  a 
dressing  for  it  which  he  calls  the  "  collodion  crust ;"  it  is 
made  by  covering  the  surface  with  dry  scraped  lint,  and 
then  with  an  additional  layer  of  lint  saturated  with  col- 
lodion. 

Every  antiseptic  precaution  is  necessary  to  prevent  or 
diminish  suppuration,  and  thereby  restrict  the  formation  of 
cicatricial  tissue.  If  strict  asepsis  is  observed  greater  ten- 
sion can  be  made  with  the  sutures  than  would  otherwise  be 
safe,  and  the  chances  of  failure  or  of  the  occurrence  of  ery- 
sipelas, for  instance,  become  less. 


CHEILOPLASTY. 

A.  Lowe?'  Lip.  Restoration  of  the  lower  lip  is  usually 
undertaken  to  make  good  the  loss  of  substance  occasioned 
by  the  removal  of  an  epithelial  tumor.  The  choice  of  a 
method  depends  upou  the  extent  of  the  disease. 

1.  M-Incision  (Fig.  105).  When  the  tumor  is  small, 
involving  not  more  than  one-quarter  or  one-third  of  the  lip, 
it  may  be  removed  by  a  V-incision,  and  the  sides  of  the  gap 
brought  together  with  one  or  two  points  of  twisted  suture. 
The  mucous  membrane  on  the  inside  of  the  lip  should  be 
excised  to  the  same  extent  as  the  skin,  although  it  is  not 
usually  involved  in  the  disease.  If  not  removed  it  forms 
a  disagreeable  fold  or  pucker  in  the  lip. 

The  harelip  pins  must  be  deeply  placed,  passing  close  to 
the  mucous  membrane  on  the  inside.  This  insures  confron- 
tation of  the  raw  surfaces  throughout  their  entire  breadth, 
and  the  pressure  of  the  twisted  sutures  prevents  hemorrhage. 

1  Reparative  Surgery,  1876,  p.  13. 


264 


OPERA  TIVE  S UR GER  Y 


2.   Oval  Horizontal  Incision  (Fig.  1 06).    When  the  tumor 
covers  a  considerable  extent  of  surface,  but  does  not  pene- 


Fig.  105. 


Cheiloplasty,  V-incision. 

trate  deeply,  it  may  be  safely  excised  by  cutting  under  it 
with  curved  scissors.     The  mucous  membrane  and  skin 

Fig.  106. 


Oval  horizontal  incision. 


may  then  be  stitched  together,  or  the  wound  allowed  to 
heal  by  granulation. 


PLASTIC  OPERATIONS  ON  THE  FACE. 


265 


3.  Method  of  Cehus  or  Serves  (Figs.  107  and  108).  The 
V-incision  is  supplemented  by  a  horizontal  one  on  each  side 
carried  outward  from  the  angle  of  the  mouth  for  about  two 
inches,  and  comprising  the  whole  thickness  of  the  cheek  for 


Fig.  107. 


Fig.  108. 


Cheiloplasty.     Celsus's  incisions.       Cheiloplasty.    Celsus's  flaps  in  place. 

the  first  two-thirds  of  its  length,  but  dividing  the  mucous 
membrane  at  a  somewhat  higher  level  than  the  skin.  The 
lower  gingivo-labial  fold  is  divided  close  to  the  gum  on 
both  sides,  and  the  dissection  carried  downward  close  to  the 
periosteum,  and  backward  toward  the  angle  of  the  jaw  until 

Fig.  109. 


Cheiloplasty.    Dieffenbach's  method. 

the  edges  of  the  gap  in  the  lip  can  be  brought  together 
without  tension.  The  sides  of  the  V  are  then  brought 
together,  and  the  lip  formed  from  the  lower  parts  of  the 
horizontal  incisions  (Fig.  108).  The  mucous  membrane 
and  skin  are  stitched  together  along  the  edge  of  the  new 
lip,  and  the  remaining  portion  of  the  lower  flap  on  each 


266 


OPERATIVE  SURGERY. 


side  (that  which  remains  external  to  the  new  angle  of  the 
mouth)  is  reunited  to  the  upper  flap.  The  mucous  mem- 
brane at  the  outer  end  of  the  horizontal  incision  is  stitched 
to  the  skin  and  covers  the  angle. 

4.  Dieffenbach  (Fig.  109)  adds  a  vertical  incision  at 
the  end  of  each  horizontal  one,  thus  marking  out  two  quad- 
rilateral flaps  which  are  brought  together  in  the  median 
line.  The  gaps  left  in  the  cheek  by  the  transfer  are  allowed 
to  close  by  granulation. 


Fig.  110. 


Fig.  111. 


Syme-Buchanan  incisions. 


Syme-Buchanan  flaps  in  place. 


5.  Syme-Buchanan  (Figs.  110  and  111).  The  method 
by  latero-inferior  flaps  is  ascribed  by  some  to  Syme,  by 
others  to  Buchanan,  of  Glasgow. 

After  the  tumor  has  been  removed  by  the  usual  V-inci- 
siou,  the  incisions  are  prolonged  downward  and  outward  for 
nearly  an  inch,  aud  then  curved  upward  and  outward. 
These  flaps  are  dissected  off  the  bone  aud  brought  together 
in  the  median  liue.  The  mucous  membrane  and  skin  are 
stitched  together  along  the  upper  edge,  the  gaps  left  below 
by  the  shifting  of  the  flaps  drawn  together  as  much  as 
possible,  and  the  remainder  left  to  heal  by  granulation. 

RanJce  aud  TrSlat  (Figs.  112  and  113)  make  the  flap  on 
one  side  longer,  and  lift  it  over  the  other  to  form  the  new 
lip,  the  shorter  flap  being  used  as  a  support  for  the  former. 

6.  BucVs  Method  (Figs.  1 14  and  115).  Buck  preferred 
to  make  two  operations.  lie  first  removed  the  tumor  by 
the  V-incision,  brought  the  sides  of  the  gap  together,  and 
allowed  them  to  unite.     After  the  union  had  become  com- 


PLASTIC  OPERATIONS  ON  THE  FACE. 


267 


plete  be  restored  the  angle  of  the  mouth  and  lengthened 
the  lower  lip  with  material  taken  from  the  upper  one  by 
the  following  method  :* 


Fig.  112. 


Fig.  113. 


In  Fig.  108,  B  B  represent  two  pins  inserted  a  finger's 
breadth  below  the  under  lip  border,  one  on  either  side  of 
the  chin,  a  little  to  the  outside  of  the  angle  of  the  mouth, 
and  equidistant  from  the  median  line ;  D  D  are  also  two 
pins  inserted,  one  on  either  side,  into  the  upper  lip  at  the 


Fig.  114. 


Restoration  of  lower  lip.    Buck's  incisions. 

margin  of  the  vermilion  border,  equidistant  from  the  me- 
dian line,  and  at  such  distance  apart  as  to  include  between 
them  sufficient  length  of  lip  border  for  a  new  upper  lip. 


1  Reparative  Surgery,  1876,  p.  22  et  seq. 


268 


OPERATIVE  SURGERY. 


The  steps  of  the  operation  are  then  the  following :  With 
the  forefinger  of  the  left  hand  placed  on  the  inside  of  the 
month,  the  left  cheek  is  to  be  kept  moderately  on  the  stretch 
while  it  is  transfixed  with  a  sharp  knife  at  the  point  B. 
An  incision  is  then  carried  through  the  entire  thickness  of 
the  cheek,  upward  and  a  little  outward,  a  distance  of  one 
inch  and  a  half  to  a  point,  E,  near  the  middle  of  the  cheek. 
The  corresponding  side  of  the  upper  lip  should  next  be 


Fig.  115. 


Restoration  of  tbe  lower  lip.    Buck's  flaps  in  place. 

transfixed  at  the  point  D,  and  the  incision  carried  through 
the  lip  and  cheek  outward  and  a  little  upward  to  join  the 
first  incision  at  JE. 

The  next  step  is  to  transfer  the  triangular  patch,  thus 
marked  out,  from  the  cheek  to  the  side  of  the  chin.  For 
this  purpose  an  incision  should  be  made  on  the  side  of  the 
chin  from  B  vertically  downward  to  the  edge  of  the  jaw 
and  to  the  depth  of  the  periosteum.  The  edges  of  this 
incision,  retracting  wide  apart,  afford  a  V-shaped  space  for 
the  lodgment  of  the  triangular  patch,  which  is  now  brought 
around  edgewise,  and  adjusted  by  sutures  in  its  new  posi- 
tion (see  Fig.  115).  The  gap  left  in  the  cheek  is  closed 
by  bringing  its  edges  together  and  securing  them  in  contact 
by  sutures.  By  this  adjustment  a  new  and  naturally  shaped 
angle  is  formed  for  the  mouth  at  the  point  J).  The  incisions 
should  be  made  with  the  utmost  precision,  and  special  care 
should  be  taken  that  the  lining  mucous  membrane  is  divided 
exactly  to  the  same  extent  as  the  skin. 

The  same  procedure  may  be  applied  to  the  other  side  of 
the  mouth,  and  executed  at  the  same  operation. 


PLASTIC  OPERATIONS  ON  THE  FACE. 


269 


7.  Square  Lateral  Flaps,  Malgaigne  (Fig.  116).  The 
tumor  is  circumscribed  by  two  vertical  incisions  carried 
downward  from  the  edge  of  the  lip,  and  a  third  horizontal 


Fig.  116. 


Cheiloplasty.    Malgaigne. 

one  unitiDg  the  lower  ends  of  the  first  two.  To  fill  the 
square  gap  thus  created,  two  horizontal  incisions  are  made 
on  each  side — one  from  the  angle  of  the  mouth,  the  other 
from  the  lower  corner  of  the  gap.  The  flaps  circumscribed 
by  these  incisions  are  brought  forward  and  united  in  the 
median  line,  and  the  mucous  membrane  stitched  to  the  skin 
along  the  edge  of  the  lip  and  at  the  commissures.  (See 
also  3.  Method  of  Celsus,  p.  265,  and  Stomatoplasty,  v. 
inf.) 

Fig.  117. 


Cheiloplasty.    Sedillot. 


8.  Square  Vertical  Flaps  (Fig.  117).     Sedillot  made  the 
flap  at  right  angles  to  the  line  of  the  mouth.    The  incisions 


270  OPERATIVE  SUEGEBY. 

are  shown  in  Fig.  117.  Each  flap  is  swung  around  to 
meet  the  other  in  the  median  line,  its  iuner  vertical  border 
becoming  the  edge  of  the  lip. 

B.  Angle  of  the  Mouth  (Stomatoplasty).  An  attempt  to 
restore  a  large  portion  of  either  lip  by  means  of  material 
taken  from  the  other,  or  to  close  a  gap  by  simple  approx- 
imation, not  infrequently  leaves  the  mouth  small,  rounded, 
and  pouting,  with  obliteration  of  one  or  both  angles.  This 
defect  can  be  overcome  by  the  operation  described  (p.  266) 
as  Buck's  method  of  restoration  of  the  lower  lip,  or  by 
extending  the  mouth  laterally  by  a  horizontal  incision  in- 
volving both  skin  and  mucous  membrane,  and  then  pre- 
venting reunion  by  stitching  the  skin  and  mucous  mem- 
brane together  on  both  sides  and  at  the  angle  of  the  incision. 
Sedillot  considers  it  indispensable  to  excise  a  portion  of  the 
skin  so  as  to  have  a  comparative  excess  of  mucous  mem- 
brane, which  when  stitched  to  the  skin  will  roll  outward 
and  form  a  vermilion  border.  This  simple  method  has 
been  modified  by  Dr.  Buck  as  follows : 

Buck's  Operation1  for  Enlargement  of  the  Mouth  and 
Restoration  of  its  Angle.  (Fig.  118.)  An  incision  is  made 
with  great  exactness  along  the  line  of  the  vermilion  border 
circumscribing  the  circular  half  of  the  mouth,  and  extending 
to  an  equal  distance  on  the  upper  and  lower  lips  (a  to  b). 
This  incision  should  only  divide  the  skin,  without  involving 
the  mucous  membrane.  A  sharp-pointed,  double-edged 
knife  should  then  be  inserted  at  the  middle  of  this  curved 
incision,  and  directed  flatwise  toward  the  cheek,  between 
the  skin  and  mucous  membrane,  so  as  to  separate  them 
from  each  other  as  far  as  the  new  angle  of  the  mouth  re- 
quires to  be  extended.  The  skin  alone  is  next  divided  from 
the  commissure  of  the  mouth  outward  toward  the  cheek. 
The  underlying  mucous  membraue  is  then  divided  in  the 
same  line,  but  not  so  far  outward.  The  angles  at  the  outer 
ends  of  the  two  incisions  are  then  accurately  united  by  a 
single  thread  suture.  The  fresh-cut  edges  of  skin  and 
mucous  membrane  above  and  below,  that  are  to  form  the 

1  Reparative  Surgery,  p.  28  et  seq. 


PLASTIC  OPERATIONS  ON  THE  FACE. 


271 


new  lip  borders,  are  shaped  by  paring  first  the  skin  and 
then  the  mucous  membrane  in  such  a  manner  that  the  latter 


Lengthening  of  the  mouth.  Buck. 


shall  overlap  the  former,  after  they  have  been  secured  to- 
gether by  fine  thread  sutures  inserted  at  short  intervals. 


Fig.  119. 


Fig.  120. 


Cheiloplasty  of  upper  lip.    Sedillot. 


Sedillot.    Flaps  in  place. 


C  Upper  Lip.     The  V-incision  and  the  oval  horizontal 
incision  (p.  264)  may  be  used  when  the  loss  of  tissue  will 


272 


OPERATIVE  SURGERY. 


be  small.     Also  the  square  lateral  flaps  (p.  269)  when  the 
2;ap  to  be  filled  is  iu  the  centre  of  the  lip  and  rather  large. 

1.  Vertical  Flaps  (Figs.  119  and  120).  These  may  be 
made  with  the  base  directed  upward  (Sedillot)  or  down- 
ward (Chauvel).  Chauvel  claims  that  the  latter  method  is 
to  be  preferred  because  the  retraction  of  the  cicatrix  in  the 
former  tends  to  draw  the  new  lip  upward  and  expose  the 
teeth. 

The  flaps  comprise  the  entire  thickness  of  the  cheek,  are 
turned  inward  at  right  angles  to  their  former  position  and 
united  in  the  median  line.  The  gaps  left  in  the  cheek  by 
their  removal  are  brought  together  with  sutures  or  left  to 
granulate. 

2.  Infero-lateral  Flap  (Buck).  Fig.  121.  For  loss  of 
the  right  half  of  the  upper  lip  Dr.  Buck  employed  the  fol- 
lowing method,  enlarging  the  mouth  afterward  and  re-estab- 
lishing the  angle  by  the  method  described  above  (p.  270) : 

Fig.  121. 


Repair  of  upper  lip  by  infero-lateral  flap.    Buck. 


The  extremity  of  the  under  lip,  where  it  joined  the  right 
cheek,  was  divided  through  its  entire  tliiekness  at  right 
angles  to  its  border,  and  the  division  carried  to  the  extent 
of  one  inch  from  the  border  (a  to  l>,  Fig.  121).  A  second 
incision  was  made  from  the  terminus  of  the  first  parallel  to 


PLASTIC  OPERATIONS  ON  THE  FACE.  273 

the  lip  border  for  a  distance  of  one  inch  and  a  half  toward 
the  chin,  6  to  c.  The  quadrilateral  flap  thus  formed  from 
the  under  lip  was  folded  edgewise  upon  itself,  and  made  to 
meet  the  remaining  half  of  the  upper  lip,  and  be  adjusted  to 
it  by  its  free  extremity.  In  order,  however,  to  make  this 
fold,  the  under  lip  had  first  to  be  divided  obliquely  half 
across  its  base,  c  to  d. 

The  left  half  of  the  upper  lip  was  prepared  for  the  new 
adjustment  by  dividing  the  buccal  mucous  membrane  close 
to  the  jaw  and  detaching  the  parts  above  toward  the  orbit 
from  the  underlying  periosteum,  and  secoudly  by  paring  a 
strip  of  vermilion  border  from  the  extremity  of  the  half-lip 
of  sufficient  length  to  permit  the  end  of  the  half-lip  to  be 
matched  to  the  free  extremity  of  the  under-lip  flap.  The 
parts  concerned  having  been  thus  prepared,  the  under-lip 
flap  was  doubled  edgewise  upon  itself,  and  its  free  extremity 
adjusted  to  the  half  of  the  upper  lip,  and  the  two  secured 
to  each  other  in  a  vertical  line  below  the  columna  nasi  by 
sutures.  The  space  between  the  newly  adjusted  half  of 
the  mouth  and  the  neighboring  cheek  was  closed  by  ap- 
proximating the  opposite  parts  and  securing  them  to  each 
other  by  sutures  after  their  edges  had  been  carefully 
matched.     (Fig.  118  shows  the  result  of  this  operation.) 


HARELIP. 

If  the  patient  is  a  youug  child  its  arms  should  be  securely 
bound  to  its  sides  with  a  towel,  and  its  head  firmly  held  by 
an  assistant.  After  anaesthesia  has  been  obtained  it  can 
be  easily  kept  up  by  applying  to  the  nostrils  from  time  to 
time  sponges  saturated  with  ether. 

Single  Harelip,  Simple.  The  simplest  method  of  opera- 
ting is  to  pare  the  sides  of  the  cleft  and  bring  the  raw 
surfaces  together  by  a  few  sutures.  The  objection  to  the 
method  is  that  the  retraction  of  the  scar  produces  a  more 
or  less  considerable  depression  in  the  free  border  of  the 
lip.  It  has  therefore  been  generally  abandoned  for  one  of 
the  following : 

1.  Double  Flaps  (Fig.  122).     In  order  to  hold  the  parts 


274  OPERATIVE  SURGERY. 

upon  the  stretch  and  insure  precision  in  making  the  cuts,  a 
stout  ligature  should  be  passed  through  the  lip  at  each 
angle  of  the  cleft,  or  each  angle  should  be  seized  with  artery 
forceps.  The  lip  beiug  drawn  forward  and  downward  by 
means  of  the  ligature  or  forceps,  the  mucous  membrane  is 
divided  close  to  the  gum  and  the  dissection  carried  upward 
and  backward  as  far  as  may  be  necessary  to  allow  the  sides 
of  the  cleft  to  be  brought  together  without  teusiou. 

Fig.  122. 


Simple  single  harelip,  double  flaps.  A.  Incisions.  B.  Flaps  turned  down.  C. 
Ligature  for  hokliug  lip  tense.  D.  Incisions  to  shorten  and  adjust  flaps.  E. 
Thread  passed  through  the  ends  of  the  flaps. 

Then  making  one  side  of  the  cleft  tense,  by  drawing  upon 
its  ligature,  the  lip  is  transfixed  near  the  angle  and  the 
incision  carried  upward  along  the  border  of  the  cleft  to  its 
top,  or,  if  necessary,  into  the  nostril,  thus  cutting  out  a 
narrow  flap  which  remains  attached  at  its  lower  extremity 
to  the  lip  (Fig.  122,  A).  A  similar  flap  is  then  made  upon 
the  other  side,  the  two  are  turned  down,  so  that  their  raw 
surfaces  face  other,  and  a  thread  passed  through  their  free 
ends  (Fig.  122,  E). 

The  freshened  edges  of  the  cleft  are  then  confronted,  a 
harelip  pin  placed  near  the  vermilion  border  and  another 
near  the  nostril,  and  two  or  three  fine  silk  or  silver  sutures 
inserted  between  them.  The  ends  of  the  dependent  flaps 
are  then  cut  off' obliquely,  enough  being  left  to  form  a  dis- 
tinct projection  on  the  lip  after  they  have  been  united  with 
fine  sutures.  By  this  means  the  formation  of  a  notch  by 
the  retraction  of  the  cicatrix  is  avoided. 

2.  When  the  cleft  was  shallow,  Nolaton  left  the  flaps 
attached  to  each  other  at  the  apex,  turned  them  down,  and 


PLASTIC  OPERATIONS  ON  THE  FACE 


275 


brought  the  raw  surfaces  together  as  above  described  (Fig. 
123.) 

3.  Single  Flap  (Fig.  1 24.)     A  flap  is  made  upon  one 
side  only,  usually  the  shorter  portion  of  the  lip.     The  oppo- 


FlG.  123. 


Harelip.    Nelaton's  method.    A.  Incision.    B.  Flap  turned  down. 

site  side  of  the  cleft,  and  a  portion  of  the  free  border  of  the 
lip  adjoining  it  are  freshened  by  the  removal  of  a  strip  of 
skin  and  mucous  membrane.     The  sides  of  the  cleft  are 


Fig.  124. 


Harelip.    Single  flap. 

approximated,  and  the  flap  applied  to  the  free  border  of 
the  lip. 

Fig.  125. 


Harelip.    Giraldes's  method. 


4    Giraldes's  Method   (Fig.  125).     This   is   applicable 
only  when  the  cleft  extends  into  the  nostril.     The  flap  on 


276  OPERATIVE  SURGERY. 

the  short  side  is  made,  as  before  described,  with  its  base 
below  ;  that  on  the  long  side  is  reversed,  being  left  attached 
at  its  upper  end.  A  third,  horizontal  incision  is  carried 
outward  from  the  edge  of  the  nostril,  at  the  point  of  the 
first  flap,  to  make  that  portion  of  the  lip  more  movable. 
The  second  flap  is  then  turned  upward  across  the  nostril, 
the  first  brought  down  to  take  its  place,  and  the  two  raw 
surfaces  thus  brought  into  contact  united  by  sutures.  The 
long  side  of  the  lip  may  also  be  mobilized,  if  desirable,  by 
a  horizontal  incision  running  from  the  gap  close  below  the 
columna  and  the  corresponding  nostril. 

Double  Harelip,  Simple  (Fig.  126).  Flaps  are  made 
upon  the  lateral  portions,  A  and  B,  as  before  described  (p. 
273,  I),  and  the  sides  of  the  central  portion,  C,  are  pared. 
The  flaps  are  then  brought  together,  as  shown  in  the  figure, 
after  mobilizing  the  lip  by  free  division  of  the  gingi vo-labial 
fold  aud  carrying  the  dissection  well  upward  and  outward, 
pins  passed  to  include  the  sides  and  the  central  portion  at 
the  base  and  apex  of  the  latter,  the  flaps  trimmed  and 
united  with  fiue  sutures. 

Fig.  126. 


Double  harelip. 

li'  the  parts  are  too  scanty  to  permit  the  use  of  this 
method,  liberating  incisions  must  be  made  around  the  ahe 
nasi,  or  flaps  obtained  from  the  cheek.  (See  Upper  Lip, 
p.  272  el  seq.) 

Complicated  Harelip.  Harelip  may  be  complicated  by 
fissure  of  the  palate  and  alveolar  process.  When  the  fissure 
is  single  the  bone  on  the  long  side  of  the  lip  projects  beyond 


PLASTIC  OPERATIONS  ON  THE  FACE.  277 

its  proper  line.  In  very  young  children,  it  may  sometimes 
be  forced  back  into  place  by  making  pressure  upon  it  with 
the  thumb,  but  it  is  easier  to  fracture  it  first  with  Butcher's 
pliers ;  the  bent  blade  of  this  instrument  being  applied  upon 
the  anterior  surface  near  the  further  nostril.  The  two  por- 
tions of  the  alveolar  arch  soon  unite  after  they  have  been 
brought  into  contact,  especially  if  the  opposing  surfaces  have 
been  pared.     Sutures  are  not  needed. 

When  there  is  double  fissure,  the  intermediate  portion  of 
bone  containing  the  incisor  teeth  projects  so  far  that  it 
seems  to  be  an  appendage  of  the  nose  rather  than  of  the 
mouth.  In  order  to  restore  it  to  its  place,  it  is  necessary  to 
divide  the  vomer  with  strong  scissors,  or,  better,  to  cut  a 
triangular  piece  out  of  the  septum  of  the  nose.  It  is  not 
necessary  to  fasten  the  bones  together  with  sutures.  The 
portion  of  skin  covering  the  projecting  bone  must  be  dis- 
sected off,  and  used  to  lengthen  the  columna  nasi  or  fill  out 
the  lip. 

In  extreme  cases  it  may  be  proper  to  cut  away  the  pro- 
jection entirely  ;  but  whenever  it  can  be  saved  and  brought 

Fig.  127. 


Cheek  compressor. 

into  line,  it  renders  valuable  service  by  giving  the  upper 
jaw  its  proper  length,  and  furnishing  a  space  into  which 
artificial  teeth  can  be  fitted.  The  three  or  four  teeth  which 
are  found  in  this  piece  are  always  so  defective  and  irregu- 
larly placed  that  they  have  to  be  drawn. 

It  is  sometimes  desirable  to  take  the  strain  off  the  sutures 

13 


278  OPERATIVE  SURGERY. 

by  means  of  a  cheek  compressor,  simular  to  that  represented 
in  Fig.  127. 

For  uranoplasty,  etc.,  see  Operations  upon  the  Mouth. 


EHINOPLASTY. 

The  different  kinds  of  rhinoplastic  operations  may  be 
classified  according  to  the  nature  and  extent  of  the  loss 
which  they  are  designed  to  repair:  1st.  A  superficial  loss 
not  involving  the  bones  or  septum.  2d.  Loss  of  the  septum 
and  nasal  bones,  the  skin  remaining  entire.  3d.  Loss  of 
more  or  less  of  the  surface  and  septum. 

As  the  loss  of  tissue  is  always  the  result  of  injury  or  dis- 
ease, it  presents  so  many  variations  in  form  and  extent,  that 
it  is  difficult  in  practice  to  determine  the  exact  boundaries 
between  the  classes,  and  this  classification  is  chosen  for  con- 
venience of  description,  and  not  with  the  intention  of  limit- 
ing the  choice  of  an  operation  in  any  given  case  to  those 
described  in  the  class  to  which  the  lesion  might  belong.  For 
the  same  reason,  a  description  of  an  operation  as  actually 
performed  will  sometimes  be  more  serviceable  than  any 
general  rules  that  might  be  laid  down. 

As  may  be  readily  understood,  the  existence  or  non- 
existence of  the  septum  and  nasal  bones  affects  materially, 
not  only  the  method  of  operating,  but  also  the  result.  If 
unsupported  centrally,  the  new  member  tends  constantly  to 
shrink  and  flatten,  and  the  surgeon  has  the  mortification  of 
seeing  that  he  has  merely  substituted  one  deformity  for  an- 
other. Oilier  tried  to  meet  this  want  by  including  the  peri- 
osteum in  the  flap  taken  from  the  forehead  by  the  Indian 
method.  There  was,  however,  no  new  formation  of  bone, 
and  the  operation  in  that  respect  was  a  failure.  On  another 
occasion  he  took  a  strip  of  healthy  periosteum  from  one  of 
the  limbs,  and  tried  to  graft  it  under  the  skin  of  the  fore- 
head, hoping  thereby  to  procure  a  lamella  of  bone,  which 
could  be  used  to  give  solidity  to  the  new  nose.  Thinking 
the  graft  had  failed,  he  withdrew  the  strip  of  periosteum 
after  a  few  days,  and  then  discovered  that  it  had  united 
nicely  at  one  point.  There  is  reason,  therefore,  to  think 
that  a  more  patient  repetition  of  the  experiment  might  be 


PLASTIC  OPERATIONS  ON  THE  FACE. 


279 


successful.  On  a  third  occasion,  he  included  the  periosteum 
of  the  forehead  in  a  flap  transferred  by  a  modification  of 
the  French  method,  and  by  folding  it  together  longitudi- 
nally along  the  centre  he  got  reproduction  of  bone  where  the 
two  layers  faced  each  other. 

1.  /Superficial  Defect  not  Involving  the  Bones  or  Septum. 
If  the  loss  of  tissue  is  confined  to  the  integument,  that  is, 
if  the  cartilage  is  spared,  as  it  usually  is  in  cases  of  epi- 
thelioma, no  plastic  operation  should  be  undertaken.  The 
tumor  must  be  carefully  dissected  off,  and  the  wound  grafted 
or  left  to  granulate.  The  slight  mobility  of  the  integu- 
ment of  the  region  prevents  deformity  by  cicatricial  retrac- 
tion, and  the  wound  heals  over,  leaving  a  scar  which  does 
not  contrast  offensively  with  the  neighboring  skin. 

If,  on  the  other  hand,  there  is  a  gap  to  be  filled,  one  that 
is  small  and  does  not  involve  the  free  border  of  the  ala, 
square  lateral  flaps  may  be  made  by  horizontal  incisions 
(Fig.  128),  and  drawn  together  after  they  have  been  ren- 
dered freely  movable  by  dissection  from  the  underlying  parts. 

Fig.  128. 


Rhinoplasty.    Lateral  flaps. 


If  the  gap  is  larger,  or  if  one  of  the  ala?  is  lost,  suitable 
oblique  or  vertical  flaps  may  be  taken  from  the  nose  or 
cheek  and  transferred  by  rotation.  Three  of  the  many 
variations  of  this  method  are  shown  in  Figs.  129  and 
130.  Fig.  129,  A,  represents  a  vertical  flap  taken  from  the 
cheek  beside  and  below  the  nose,  and  left  adherent  at  its 


280 


OPERA  TIVE  SURGER  Y. 


upper  end.  The  flap  should  be  cut  long  enough  to  allow  a 
natural  appearance  to  be  given  to  the  free  border  of  the  ala 
by  turning  it  in  upon  itself.  This  device  will  also  prevent 
excessive  cicatricial  contraction  of  the  border  and  conse- 
quent narrowing  of  the  nostril. 


Fig.  129. 


Fig.  130. 


Rhinoplasty.    A.  Single  lateral  flap. 
B.  Langenbeck's  method. 


Rhinoplasty.    Denonvillier's  method. 


Denonvillier's  Method  (Fig.  130)  sometimes  makes  it 
possible  to  secure  this  object  more  certainly  by  supplying 
a  border  that  is  already  cicatrized.  Supposing  the  lower 
portion  of  an  ala  to  be  lost,  a  triangular  flap,  left  adherent 
to  the  lobe  of  the  nose,  is  marked  out  by  an  incision  which, 
starting  from  a  point  near  the  lobe  on  the  unaffected  side  of 
the  median  line,  is  carried  directly  upward  nearly  to  the 
root  of  the  nose,  and  thence  obliquely  downward  to  the 
upper  outer  corner  of  the  affected  ala.  The  flap  is  mobi- 
lized by  careful  dissection  of  the  bone  and  cartilage,  and 
transferred  downward.  The  gap  left  by  the  transfer  heals 
by  granulation  or  can  be  closed  by  a  Thiersch  graft.  For 
the  sake  of  giving  more  stiffness  to  the  border,  Denonvil- 
lier  sometimes  included  a  strip  of  cartilage  in  it. 

Von  LangenbecW  restored  an  ala  by  taking  a  triangular 
flap  from  the  opposite  side  of  the  nose  (Fig.  129,  B).  The 
flap  was  left  adherent  at  the  apex  of  the  triangle,  which 
lay  near  the  inner  angle  of  the  eye  of  the  affected  side, 


I.  gaisde  Chirm-gin  I'lastique  d'apres  les  Preceptes  du  Prof.  B.  von  Langen- 
bcek,  Bruxelles,  18.r>ii,  quoted  by  Vernuuil. 


PLASTIC  OPERATIONS  ON  THE  FACE.  281 

while  its  base  occupied  the  opposite  ala.  It  was  dissected 
up  carefully  so  as  not  to  include  the  cartilage,  transferred 
to  the  other  side,  and  fasteued  to  the  freshened  edges  of  the 
gap.  The  wound  left  by  the  removal  of  the  flap  healed  by 
grau ulation,  and  so  perfectly  that  it  was  difficult  to  recog- 
nize there  had  been  any  loss  of  tissue  at  that  point. 

Michon  restored  the  ala  by  taking  a  triangular  flap  from 
the  septum.  The  base  of  the  flap  was  placed  anteriorly, 
parallel  to  the  ridge  of  the  nose,  and  the  apex  lay  near  the 
junction  of  the  septum  with  the  floor  of  the  nasal  fossa. 
The  flap  was  dissected  up  and  attached  to  the  margin  of  the 
loss  of  substance,  its  mucous  surface  directed  outward,  its 
apex  made  fast  to  the  cheek. 

The  columna,  with  or  without  the  tip  of  the  nose,  can  be 
restored  from  the  upper  lip.  Dupuytren  and  Dieffenbach 
cut  a  vertical  cutaneous  flap,  adherent  at  its  upper  end,  im- 
mediately below  the  columna,  turned  it  upward,  twisting 
it  upon  its  pedicle  so  that  its  cutaneous  surface  remained 
external,  and  secured  it  in  place.  As  the  twisting  of  the 
pedicle  created  considerable  deformity,  Sedillot  and  Blandin 
made  the  flap  of  the  entire  thickness  and  length  of  the  lip, 
pared  off  its  cutaneous  surface,  and  turned  it  directly 
upward  without  twisting  the  pedicle,  the  mucous  membrane 
thus  forming  the  outer  surface.  The  gap  left  in  the  lip  was 
then  closed  with  sutures.  In  Blaudin's  case  the  result  was 
excellent,  and  the  mucous  membrane  gradually  assumed  the 
characteristics  of  ordinary  skin  ;  but  in  Sedillot's  case,  in 
which  the  tip  of  the  nose  had  also  to  be  restored,  the  mem- 
brane remained  red  and  covered  with  thick  epidermic  scales, 
and  the  end  of  the  nose  looked  much  like  a  cherry.1  In 
all  his  rhinoplastic  operations  Liston  made  the  columna 
separately  by  this  method,  and  found  that  the  mucous  mem- 
brane soon  took  on  the  appearance  of  ordinary  integument. 

2.  Loss  of  the  Septum  and  Nasal  Bones,  the  SM71  re- 
maining entire.  Baron  Larrey,  about  1820,  operated  upon 
a  soldier  the  bridge  of  wrhose  nose  had  been  shattered  and 
depressed  by  the  explosion  of  a  gun.  He  removed  the  de- 
formity by  dissecting  up  the  adherent  portions  of  skin  and 

1  Sedillot :  Medecine  Operatoire,  2d  ed.,  vol.  ii.  p.  233. 


282 


OPERATIVE  SURGERY. 


replacing  them  in  their  original  position.     The  details  of 
the  operation  are  lacking. 

Dietfenbach  published  in  1829  the  description  of  an  ope- 
ration by  which  he  overcame  the  great  deformity  resulting 
from  the  loss  of  the  septum  and  bones  of  the  nose  by  scro- 
fulous disease.  As  the  case  is  a  classical  one,  quoted,  aud 
often  very  incorrectly,1  in  the  text-books,  and  is  an  indica- 


Fig.  131. 


Dieffenbach's  operation.    B.  The  result.    C.  The  flaps. 

tion  of  what  may  sometimes  be  accomplished  in  extreme 
cases,  the  following  description  of  it  is  given  :2 

The  patient  was  a  girl  twelve  years  of  age.  She  had 
lost  the  ossa  nasi,  nasal  process  of  the  ethmoid,  vomer,  and 
cartilages,'  and  instead  of  a  prominent  nose  there  was  a 
deep  pit  with  a  ridge  at  the  bottom.  The  plan  of  opera- 
tion was  to  divide  the  remains  of  the  old  sunken  member 
into  portions,  raise  them  up,  aud  secure  them  in  the  proper 
position.     Dieffenbach  passed  a  narrow-bladed  knife  first 


i  The  description  in  Holmes's  System  of  Surgery,  vol.  v.  p.  670,  is  almost  nn- 
recognizable.  It  is  taken  from  Malgalgne's  incorrect  account,  and  also  contains 
al  leiist  one  gross  error  in  translation 

-  As  the  original  work  could  not  be  obtained,  this  description  is  made  up  from 
BH    English  translation  of  the  hook,  published  in   1888,  a  French  translation  of 

the  case  in  the  Gazette  Mfidlcale,  vol.  i.  p.  65. 1880,  and  a  brief  description  with 
plates,  in  a  collection  of  Dieffenbach'fi  riaslic  Operations,  published  by  two  of 
hi:-  pupils  in  1846, 


PLASTIC  OPERATIONS  ON  THE  FACE.  283 

iuto  one  nostril  and  then  into  the  other,  and  cut  out,  mak- 
ing two  incisions,  one  on  each  side  of  the  sunken  ridge 
(Fig.  131,  C).  The  strip  of  skin  between  these  incisions 
was  three  times  as  broad  at  its  lower  end,  where  it  was  con- 
nected with  the  upper  lip  by  the  shortened  columna,  as  at 
its  upper  part  where  it  joined  the  forehead.  The  cheeks 
were  next  cut  through  down  to  the  bones  on  each  side  by 
inserting  the  knife  a  few  lines  below  the  upper  end  of  the 
first  incision  and  carrying  it  obliquely  downward,  parallel 
and  a  little  external  to  the  side  of  the  nose,  and  then  around 
into  the  nostril,  thus  separating  the  lateral  attachments  of 
the  alse  nasi.  The  columna,  being  too  short,  was  then 
elongated  by  two  slight  incisions  in  the  upper  lip,  and  the 
cheeks  rendered  more  movable  by  dividing  their  attach- 
ments to  the  bone  through  the  lateral  incisions.  The  flaps 
were  then  raised,  the  sides  of  the  incisions  pared  obliquely 
in  a  manner  to  which  Dieffenbach  attaches  an  importance 
that  seems  undeserved,  reunited,  and  fixed  with  harelip 
pins  and  sutures,  and  the  whole  retained  in  place  by  draw- 
ing the  cheeks  toward  the  median  line  and  fastening  them 
there  with  two  long  pins  passed  under  the  nose  and  through 
the  detached  edges  of  the  cheeks.  This  compression  was 
aided  by  two  splints  of  leather  through  which  the  pins 
passed.  A  quill  covered  with  oiled  lint  was  introduced  into 
each  nostril. 

Osteoplastic  Method.  Oilier  treated  successfully  a  some- 
what similar  case  by  making  a  triangular  flap,  its  base  con- 
stituted by  the  lower  portion  of  the  nose  and  the  adjoining 
cheeks,  its  apex  situated  one  and  a  half  inches  above  the 
eyebrows.  The  frontal  portion  of  the  flap  included  the 
underlying  periosteum.  The  left  nasal  bone  and  vomer 
having  been  destroyed  by  the  disease,  central  support  could 
be  obtained  for  the  new  nose  only  by  aid  of  the  right  nasal 
bone,  which  was  accordingly  loosened  with  a  chisel  and 
forced  downward.  The  flap  was  then  transferred  down- 
ward, pinched  in  laterally  to  increase  its  height  at  the  bridge, 
and  supported  there  by  drawing  the  cheeks,  previously 
loosened  from  their  underlying  attachments,  toward  the 
nose  and  fastening  them  there  with  long  pins.1 

1  For  further  details  of  this  operation  the  reader  is  referred  to  the  original  ac-- 
count  in  the  Bulletin  de  la  SociSte  de  Chirurgie,  1862.  p.  62,  or  to  its  reproduction 


284 


OPERATIVE  SURGERY. 


Double  Layer,  or  Superficial  Flaps  (Fig.  132).  Ver- 
neuil1 employed  successfully  a  method  suggested  to  him  by 
Oilier,  iu  which  permanent  elevation  of  the  bridge  of  the 
nose  was  secured  by  superposiug  two  flaps  and  thereby  doub- 
ling the  thickness.  The  patient  had  discharged  a  pistol 
into  his  mouth,  causing  the  destruction  of  a  portion  of  the 
hard  palate  and  septum,  the  nasal  bones,  part  of  the  nasal 
processes  of  the  superior  maxillary,  the  spine  of  the  fron- 
tal, and  the  anterior  wall  of  the  frontal  sinuses.  The  alye 
and  lobe  were  uninjured  but  much  flattened  ;  above  them 
was  a  broad  deep  groove  extending  to  the  middle  third  of 
the  forehead.  The  two  principal  indications  were  to  bring 
the  lateral  portions  nearer  the  median  line  and  to  reconsti- 
tute the  bridge  of  the  nose.  The  latter  could  be  perma- 
nently accomplished  only  by  filling  in  the  great  cavity 
which  would  be  left  by  raising  the  sunken  parts. 

Fig.  132. 


-i_i* 


Rhinoplasty,  sunken  nose.    Double  layer,  or  superposed  flaps.    Verneuil. 

Verneuil  made  an  incision  along  the  median  line  of  the 
depression  and  a  transverse  one  at  each  end  of  the  first, 
and  dissected  up  the  two  lateral  flaps  thus  marked  out. 
He  then  raised  an  oblong  flap  from  the  middle  of  the  fore- 
head, its  base  remaining  adherent  between  the  eyebrows, 

in  Verneuil's  Chirurgie  Koparatrice,  p.  428,  and  in  the  Gazette  Hebdomadaire, 
I  -v>i.  \).  !«,  and  also  to  a  similar  operation  described  more  fully  on  pp.  288,  289  of 
i  hie  manual, 
I  Chirurgie  Rc'-paratrice,  p.  428,  and  Hull,  de  la  Soc.  do  Chirurgie,  18G2,  p.  70. 


PLASTIC  OPERATIONS  ON  THE  FACE.  285 

and  turned  it  directly  downward  so  that  its  raw  surface 
was  directed  outward,  its  tegumentary  surface  toward  the 
nasal  fossae.  The  two  lateral  flaps  were  then  placed  upon 
it  and  united  in  the  median  line.  The  raw  surfaces  united 
with  each  other,  and  the  result  was  a  nose  elevated  one- 
third  of  an  inch  above  the  adjoining  surface. 

Subcutaneous  Method.  Prof.  Pancoast1  operated  upon 
a  similar  case  in  the  winter  of  1842-43  by  subcutaneous 
division  of  the  adhesions.  The  ossa  nasi  and  septum  had 
been  entirely  destroyed  by  disease,  and  the  nose  was 
sunken  far  below  the  level  of  the  face.  "  A  narrow  long- 
bladed  tenotomy  knife  was  introduced  on  either  side  by 
puncture  through  the  skin  over  the  edge  of  the  nasal  pro- 
cess of  the  upper  maxillary  bone.  The  knife  was  pushed 
up  under  the  skin  to  the  top  of  the  nasal  cavity,  and  then 
brought  down,  shaving  the  inside  of  the  bony  wall,  so  as 
to  detach  the  adherent  and  inverted  nose  upon  either  side. 
The  point  of  the  nose  could  now  be  drawn  out.  .  .  .  The 
nose  still  remained  adherent  to  the  top  of  the  nasal  chasm. 
The  knife  was  a  third  time  introduced  under  the  skin  in  a 
direction  corresponding  nearly  with  the  long  diameter  of 
the  orbits  of  the  eyes  and  the  adhesions  separated  from 
the  nasal  spine  and  internal  angular  processes  of  the  os 
frontis."  The  soft  parts  on  the  cheek  were  loosened  by 
sweeping  the  knife  outward  along  the  surface  of  the  bone 
so  far  as  to  divide  the  infra-orbital  nerve  and  artery  on 
each  side,  drawn  toward  the  median  line,  and  held  to- 
gether with  quilled  sutures  passed  through  the  cavity  of  the 
nose. 

In  two  weeks  the  root  of  the  new  nose  had  sunk  to  the 
level  of  the  face,  but  the  patient  was  well  satisfied,  and 
refused  any  further  operation,  beyond  the  removal  of  an 
elliptical  piece  of  skin  to  raise  this  portion  again.  The 
ultimate  result  is  not  known. 

Dubrueil2  quotes  a  similar  operation  by  Malgaigne,  but 
without  giving  the  date.  As  it  is  not  mentioned  in  the  lat- 
ter's  Medecine  Operatoire,  edition  of  1837,  it  is  probable 
that  Prof.  Pancoast's  operation  autedates  it. 

1  Operative  Surgery,  Phila.,  1852,  p.  858.  -  Medecine  Operatoire,  p.  451. 

13* 


286 


OPERATIVE  SURGERY. 


3.  Loss  of  more  or  less  of  the  Surface  and  the  Septum. 

A.  Indian  Method.  This  method  was  introduced  into 
Europe  in  1814,  by  Carpue,  an  Euglish  surgeon,  and  the 
stimulus  given  by  it  to  this  class  of  operations  was  so  great 
during  the  succeeding  twenty-five  or  thirty  years  that  this 
period  has  been  called  that  of  the  renaissance  of  rhinoplas- 
ty surgery.  The  ultimate  results,  however,  were  not  very 
favorable,  and  the  method  has  fallen  iuto  comparative 
neglect.  It  was  found  that  the  noses,  although  sufficiently 
full,  or  even  excessive  at  the  time  of  the  operation,  under- 
went gradual  atrophy,  and,  when  central  support  was  lack- 
ing, sank  to  the  level  of  the  cheeks.  The  nostrils,  too, 
closed  sometimes  to  such  an  extent  that  they  would  hardly 
admit  a  probe ;  and,  finally,  the  whole  flap  had  a  tendency 
to  slide  downward,  and  collect  in  a  lump  at  the  end  of  the 
nose  after  division  or  excision  of  the  pedicle.  The  scar 
left  upon  the  forehead  was  a  serious  disfigurement,  and  the 
attempt  to  diminish  it  by  drawing  the  sides  of  the  gap  to- 
gether gave  rise  to  complications,  which  endangered  the 
patient's  life.  The  operation  itself  was  not  without  dan- 
ger. Dieffenbach  lost  two  out  of  six  patients  upon  whom 
he  operated  in  Paris. 

Fig.  133. 


Rhinoplasty.    Indian  method  unmodified. 

The  operation  was  originally  performed  as  follows  (Fig. 
133):  A  flap,  the  size  and  shape  of  which  were  determined 
by  a  pattern  previously  made  of  paper  or  card,  was  marked 


PLASTIC  OPERATIONS  ON  THE  FACE  287 

out  upon  the  forehead  immediately  above  the  nose.  Care 
was  taken  to  make  it  at  least  a  quarter  of  an  inch  broader 
and  half  an  inch  longer  than  the  space  it  was  to  fill.  Its 
base  was  situated  between  the  eyebrows,  and  was  half  an 
inch  broad.  At  the  upper  end  of  the  flap  was  a  projecting 
tab  intended  to  form  the  columna.  The  flap,  including  all 
the  tissues  down  to,  but  not  through,  the  periosteum,  was 
then  dissected  up,  brought  down  by  twisting  the  pedicle, 
placed  in  its  new  position  with  its  raw  surface  inward,  and 
attached  by  sutures  to  the  freshened  edges  of  the  gap  it  was 
to  fill.  Prominence  was  given  to  the  ridge  by  stuffing  the 
nostrils  with  plugs  of  oiled  lint,  or  drawing  the  cheeks 
toward  the  median  line  by  means  of  long  pias  passed  trans- 
versely through  the  edges  and  under  the  nose.  The  gap  in 
the  forehead  was  left  to  heal  by  granulation.  After  the 
flap  had  united,  the  pedicle  was  divided,  and  returned  to 
its  original  position. 

Modifications.1  Larrey  (1820)  pointed  out  the  desira- 
bility of  saving  even  the  smallest  fragments  of  the  original 
nose,  especially  if  they  belonged  to  the  free  border  of  the 
ala.  Prof.  Bouisson2  formulated  this  principle,  and  ex- 
tended it  to  the  other  methods,  as  follows:  1st.  Save  as 
much  as  possible  of  the  septum.  2d.  Give  lateral  support 
to  the  flaps  by  means  of  the  healthy  portion  of  the  carti- 
lage of  the  alee.  3d.  Insure  the  regularity  of  the  outline 
of  the  nostril  by  giving  the  lower  border  of  the  flap  carti- 
laginous support.  Dupuytren  and  Dieifenbach  opposed 
the  retraction  and  closure  of  the  nostrils  by  folding  back 
upon  itself  that  portion  of  the  edge  of  the  flap  which  was 
to  form  the  free  border. 

The  torsion  of  the  pedicle  involves  more  or  less  danger 
of  gangrene  by  obstructing  the  return  of  the  venous  blood. 
Lisfranc  (1826)  was  the  first  to  attempt  to  diminish  this 
defect.  By  lengthening  the  incision  on  one  side,  the  base 
or  attachment  of  the  pedicle  was  made  oblique  instead  of 
transverse,  and  the  torsion  correspondingly  diminished  at 

i  The  dates  of  these  modifications,  and  the  award  of  credit  for  their  sugges- 
tion are  mainly  taken  from  Verneuil's  Chirurgie  Reparalrice,  to  which  the  reader 
is  referred  for  further  details  and  documentary  proof. 

2  Rhinoplastie  laterale. 


2 >  s  OPERA  TIVE  S UR GER  Y. 

that  point.  Of  course,  the  total  amount  of  torsion  re- 
mained the  same,  but,  by  being  spread  along  the  pedicle,  it 
was  made  more  spiral  and  less  abrupt.  Von  Laugenbeck 
(before  1856)  went  a  step  further,  and  put  the  base  upon 
the  side  of  the  nose  close  to  the  eye,  the  upper  incision  end- 
ing at  the  eyebrow,  the  lower  just  below  the  tendo  oculi. 
Labbat  did  about  the  same  thing  in  1827. 

Auvert,  a  Russian  surgeon  (date  unkuown,  but  long  be- 
fore 1850),  made  the  flap  oblique  instead  of  vertical,  still 
keeping  the  base  between  the  eyebrows.  Alquie,  of  Mont- 
pellier  (1850),  proposed  to  make  the  flap  horizontal,  the 
lower  incision  being  hidden  by  the  eyebrow  ;  and  Landreau 
even  curved  it  somewhat  upward  at  the  end,  so  that  the 
base  of  the  pedicle  was  hardly  twisted  at  all  in  bringing 
down  the  flap.  Ward  (1854)  madf  a  flap  which  was  di- 
rected obliquely  upward,  and  Follin  (1856)  made  a  trans- 
verse one ;  in  each  case  the  base  of  the  pedicle  was  upon  or 
near  the  median  line  of  the  forehead,  a  little  above  the 
evebrows.  Both  cases  did  well.  The  objection  to  a  trans- 
verse flap  is  that  the  retraction  of  the  cicatrix  upon  the 
forehead  draws  the  corresponding  eyebrow  upward.  The 
advantages  are  that  the  torsion  is  less,  and  the  scar  some- 
what disguised  by  the  natural  lines. 

Various  means  have  been  employed  to  prevent  the  descent 
of  the  flap.  Dieffeubach  made  a  longitudinal  incision  on 
the  side  of  the  nose,  and  engaged  the  pedicle  in  it,  paring 
off  its  prominences  afterward.  JBlaudin  excised  the  portion 
of  skin  intermediate  between  the  base  of  the  pedicle  and 
the  loss  of  substance,  and  thus  obtaiued  a  raw  surface  to 
which  the  whole  length  of  the  pedicle  was  then  united. 
Instead  of  excising  this  intermediate  piece  of  skin,  Buck 
left  it  attached  by  its  upper  end,  and  used  it  to  cover  part 
of  the  gap  left  upon  the  forehead.  Velpeau  divided  the 
pedicle  close  to  its  base,  trimmed  it  to  a  point,  and  engaged 
it  in  a  vertical  incision  made  in  the  underlying  skin. 

B.  Ollier's  Osteoplastic  Method1  (Fig.  134).  A  lupus 
had  destroyed  the  alae,  columna,  lobe,  cartilages,  and  part 
of  the  septum.  The  nasal  bones  were  uninjured,  but  had 
suffered  an   arrest  of  development,  and  were  bounded  in— 

1  Traite  de  la  Regeneration  des  Os,  vol.  ii.  p.  469. 


PLASTIC  OPERATIONS  ON  THE  FACE. 


289 


feriorly  by  a  strip  of  cartilage.  The  nose  was  not  more 
than  an  inch  long.  The  skin  of  the  cheeks  and  lips  had 
also  been  involved  by  the  lupus,  and,  therefore,  could  not 
be  used  for  the  restoration. 

Starting  from  a  point  in  the  median  line  of  the  forehead 
two  inches  above  the  eyebrows,  Oilier  made  two  incisions 
diverging  downward,  each  of  which  ended  a  quarter  of  an 
inch  to  the  outer  side  of  the  lower  border  of  the  nasal 
orifice. 

In  dissecting  up  the  long  triangular  flap  thus  marked 
out,  he  included  the  periosteum  from  above  downward  as 
far  as  to  the  upper  end  of  the  nasal  bones ;  he  then  con- 
tinued the  dissection  along  the  right  nasal  bone,  leaving  the 
periosteum  adherent  to  it,  and  on  reaching  the  lower  end 
of  the  bone  he  separated  from  it  the  cartilaginous  strip 
above  mentioned,  leaving  it  adherent  to  the  flap. 

On  the  left  side  he  divided,  with  a  chisel,  the  bony  con- 
nections of  the  left  nasal  bone,  leaving  the  bone  attached  to 
the  flap  by  its  anterior  surface ;  this  was  accomplished  by 
introducing  the  chisel,  first  between  the  two  nasal  bones, 


Fig.  134. 


Rhinoplasty.    Ollier's  osteoplastic  method. 

then  between  the  left  nasal  bone  and  the  frontal,  and  finally 
between  the  left  nasal  bone  aud  the  nasal  process  of  the 
superior  maxillary.  Drawing  the  flap  downward,  he  then 
divided  the  cartilaginous  septum  from  before  backward  and 


290  OPERATIVE  SURGERY. 

downward  with  scissors,  so  as  to  have  au  antero-posterior 
flap  of  cartilage  attached  by  its  base  to  the  cutaneous  one, 
and  able  to  furnish  central  support  for  the  new  nose  by 
resting  its  free  border  upon  the  floor  of  the  nasal  fossa,  or 
rather  upon  the  rernaius  of  the  lower  portion  of  the  origi- 
nal septum. 

He  next  drew  the  whole  flap  downward  until  the  upper 
border  of  the  left  nasal  boue  came  into  Hue  with  the  lower 
border  of  the  right  nasal  bone,  and  then  fastened  the  two 
bones  together  with  a  metallic  suture.  The  sides  of  the 
flap  were  then  united  to  the  cheeks,  and  those  of  the  frontal 
incisions  drawn  together  above  the  apex  of  the  flap. 

The  parts  united,  the  space  left  by  the  removal  of  the 
left  nasal  boue  was  filled  with  bone  produced  by  the  perios- 
teum brought  down  from  the  forehead,  and  the  result  was 
satisfactory. 

C.  Alquie  used  a  flap  of  similar  shape  in  a  case  in  which 
the  alse  and  septum  were  lost,  but  the  columna  remained. 
The  apex  of  the  triangle  was  placed  in  the  space  between 
the  eyebrows,  and  the  incisions  diverged  downward  and 
outward.  With  a  narrow  tenotome  passed  along  the  in- 
cisions he  separated  the  skin  entirely  from  the  nasal  bones 
and  was  then  able  to  depress  it  far  enough  to  attach  it  to 
the  freshened  end  of  the  columna. 

D.  Italian  Method  (Fig.  135).  Tagliacozzi  made  two 
nearly  parallel  incisions  along  the  anterior  surface  of  the 
arm,  their  length  aud  the  distance  between  them  varying 
according  to  the  size  of  the  gap  the  flap  was  to  fill.  The 
apex  of  the  flap  was  directed  toward  the  shoulder.  The 
intermediate  strip  of  skin  was  dissected  up,  but  left  adherent 
at  both  ends,  and  a  piece  of  oiled  lint  passed  under  it  and 
kept  there  until  suppuration  was  established.  The  strip 
was  then  cut  free  at  its  upper  end,  and  dressed  carefully  for 
about  a  fortnight,  or  until  its  under  surface  was  nearly  cica- 
trized. It  was  then  considered  fit  to  be  applied,  having 
undergone  the  necessary  shrinking  and  thickening.  Its 
(flues  and  those  of  the  nasal  aperture  were  pared  and  fast- 
ened together  with  sutures,  and  the  arm  bound  fast  to  the 
head.  When  union  had  taken  place  between  the  two,  the 
Lower  end  of  the  Hap  was  cut  loose  from  the  arm  and  its 
edges  trimmed  to  the  proper  shape. 


PLASTIC  OPERATIONS  ON  THE  FACE. 


291 


Graefe  did  not  let  the  flap  suppurate,  but  tried  to  get 
primary  union. 


Fig.  135. 


Rhinoplasty.    Italian  method. 

Dr.  Thomas  T.  Sabine  successfully  filled  by  the  im- 
plantation of  a  finger  the  gap  left  by  the  destruction  of  the 
nose. 


PLASTIC   OPERATIONS    UPON    THE    EYELIDS. 

In  these  operations  it  is  important  to  save  as  much  as 
possible  of  the  original  tissues,  especially  the  free  border  of 
the  lid,  the  conjunctiva,  and  the  orbicular  muscle.  As  the 
skin  is  thin  and  delicate,  the  flaps  must  have  broad  bases 
to  insure  their  vitality;  they  must  also  be  so  placed  that 
their  natural  retraction  will  not  tend  to  re-establish  the  pre- 
vious defect. 

Blepharorrhaphy.  Suture  of  the  eyelids  has  proved  a 
very  valuable  adjunct  of  many  of  the  plastic  operations  upon 


292  OPERATIVE  SURGERY. 

the  eyelids,  and  has  even  taken  the  place  of  some  of  them, 
for  experience  has  shown  that  a  loss  of  substance  in  either 
eyelid  may  be  safely  allowed  to  fill  and  heal  by  granulation 
if  the  borders  of  the  lids  are  kept  fastened  together.  The 
eye  must  be  kept  closed  in  this  way  for  six  months  or  a 
year,  after  which  time  the  scar,  in  most  cases,  shows  no  ten- 
dency to  retract.  When  the  time  comes  to  separate  the 
lids,  this  should,  at  first,  be  done  for  only  half  an  inch  in 
the  centre,  and  the  opening  subsequently  enlarged  at  long 
intervals  of  time,  any  indication  of  cicatricial  retraction 
being  meanwhile  watched  for. 

The  prolonged  occlusion  does  no  harm  to  the  eye  ;  on 
the  contrary,  it  may  be  sufficient  in  itself  to  cure  a  com- 
mencing keratitis  occasioned  by  ectropion. 

Operation.  A  narrow  strip  of  conjunctiva  is  excised 
from  the  border  of  each  lid  on  the  conjunctival  side  of  the 
lashes,  beginning  and  ending  a  short  distance  from  thecom- 

Fig.  136. 


Canthoplasty.    A.  Straight  incision.    B.  Richet's  modification. 

missures,  so  as  to  leave  a  space  for  the  flow  of  the  tears. 
The  two  raw  surfaces  are  then  brought  together  accurately 
with  silver  sutures. 

To  separate  the  lids  afterward  a  director  should  be  en- 
tered at  the  opening  left  at  one  of  the  angles,  its  point 
pressed  against  the  centre  of  the  line  of  union,  and  cut 
down  upon  the  two  rows  of  lashes. 

Canthopla8ty.  Enlargement  of  the  palpebral  opening 
(Fig.  136).  The  external  angle  of  the  eye  is  divided  hori- 
zontally with  scissors,  and  the  skin  and  conjunctiva  united 


PLASTIC  OPERATIONS  ON  THE  FACE. 


293 


along  the  sides  of  the  incision  by  three  points  of  sutures, 
one  of  them  being  placed  at  the  angle. 

Richet's  modification1  (Fig.  136,  B).  Richet  marks  out 
a  small  flap  by  two  incisions  through  the  skin,  beginning  at 
opposite  points  on  the  upper  and  lower  lids  near  the  outer 
angle  and  meeting  at  a  point  external  to  that  angle.  The 
flap,  including  everything  except  the  conjunctiva,  is  then 
excised,  the  conjunctiva  split  horizontally,  and  its  two  por- 
tions trimmed  and  fastened  to  the  edge  of  the  cutaneous 
incisions. 

Blepharoplasty,  to  prevent  or  remedy — 

1.  Ectropion.  The  descriptions  will  be  given  for  the 
lower  lid  only,  that  being  the  more  frequent  seat  of  the  de- 
formity. Blepharoraphy  (q.  v.)  is  often  sufficient  in  itself 
to  prevent  ectropion,  and  is  always  a  useful  adjunct  of  a 
plastic  operation.  The  lids  should  be  kept  united  during 
the  process  of  cicatrization  of  the  wound  left  by  the  loss  of 
substance,  and  for  several  months  thereafter. 

Wharton  Jones  (Fig.  137).  Wharton  Jones  included 
the  contracted  cicatrix  in  a  triangular  flap  one  inch  high, 
its  base  occupying  nearly  the  whole  length  of  the  lid  border. 

Fig.  137. 


Ectropion.    Wharton  Jones. 


By  dividing  the  bands  of  cellular  tissue,  but  without  dis- 
secting up  the  flap,  he  restored  the  lid  to  its  normal  position, 
and  held  it  there  by  uniting  the  edges  of  the  incision  below, 
thus  giving  it  the  form  of  a  Y. 


1  Anatomie  Medico-Chirurgicale,  4th  edition,  p. 


294 


OPERA  TIVE  S  UE  GEE  Y. 


Alphonse  Guerin1  (Fig.  138)  makes  two  incisions  form- 
ing an  inverted  V,  the  point  of  which  lies  just  below  the 
centre  of  the  free  border  of  the  lid.  From  the  lower  ex- 
tremities of  these  incisions  he  makes  a  third  and  fourth 
parallel  to  the  border  of  the  lid.  The  two  triangular  flaps 
bounded  by  the  1st  and  3d,  and  the  2d  and  4th  incisions 


Fig.  138. 


• 


1  t  %  O 


Ectropion.    Alphonse  Guerin. 


are  then  dissected  up,  the  lid  raised  to  its  normal  position, 
and  held  there  by  uniting  the  adjoining  sides  of  these  two 
flaps  in  such  a  manner  that  their  apices  and  that  of  the  in- 
verted V  meet  at  a  common  point.  The  gaps  left  by  the 
removal  of  the  two  flaps  are  allowed  to  granulate,  or  cov- 
ered with  Thiersch  grafts.  For  greater  security  Guerin 
also  unites  the  borders  of  the  lids  (blepharoraphy). 

Fig.  139. 


M 


Ectropion.    A.  Von  Graefe's  method.    B.  Knapp's  method. 


Von  Graefe  (Fig.  139,  A).  Make  an  incision  along  the 
border  of  the  lid  just  outside  of  the  lashes  from  the  lach- 
rymal  point  to  the  external  commissure.  From  each  ex- 
tremity of  tliis  make  a  vertical  incision  downward  from  one- 


i  Chirurgie  Op6ratoire,  4th  edition,  p.  318. 


PLASTIC  OPERATIONS  ON  THE  FACE.  295 

half  to  three-quarters  of  an  inch  in  length.  These  incisions 
should  involve  only  the  skin.  Cut  off  the  upper  inner  cor- 
ner of  this  flap,  not  by  a  straight  incision,  but  by  one  form- 
ing an  angle,  as  shown  in  the  figure,  and  fasten  this  angle 
by  a  suture  to  that  formed  by  the  border  of  the  lid  and  the 
inner  vertical  incision.  Reunite  the  edges  of  the  transverse 
incision,  cutting  the  euds  of  the  sutures  long  enough  to 
reach  to  the  forehead,  and  then  fastening  them  there  with 
adhesive  plaster.  The  excision  of  the  inuer  angle  of  the 
flap  raises  the  eyelids  by  shortening  its  border. 

Dieffenbaeh,  Adams,  and  Ammon  have  proposed  other 
methods  of  shortening  the  lid.  They  are  indicated  in  Fig. 
140,  where  the  shaded  spaces  represent  the  portions  of  skin 
to  be  removed,  and  the  threads  the  manner  in  which  the 
edges  are  afterward  brought  together.  Adams's  excision 
included  the  whole  thickness  of  the  lid. 

Richet  (Fig.  141).  Richet  makes  an  incision  parallel  to 
the  border  of  the  lid,  half  an  inch  below  it,  and  extending 
nearly  from  one  angle  of  the  eye  to  the  other.  The  lid, 
having  been  freed  by  this  incision,  is  then  united  to  the 
other  (blepharoraphy). 

Rg.  140. 


0  V  B 

Ectropion.  A.  Dieffenbaeh.  B.  Adams.  C.  Amnion.  The  shaded  spaces  indi- 
cate the  portions  of  skin  removed  ;  the  threads  show  how  their  edges  are  brought 
together. 

He  next  makes  a  second  incision  parallel  to  the  first  and 
one-third  of  an  inch  below  it,  divides  the  intermediate  strip 
of  skin  vertically  in  the  middle  and  dissects  up  its  two 
halves.  Immediately  below  the  lower  end  of  this  vertical 
incision  he  removes  from  the  lower  border  of  the  second 
incision  a  V-shaped  flap  of  skin,  its  point  directed  down- 
ward. He  then  raises  the  two  halves  of  the  middle  flap, 
brings  them  again  into  contact  with  the  border  of  the  lid, 


296 


OPERATIVE  SURGERY. 


excises  their  superfluous  length,  and  unites  them.  The 
sides  of  the  V  are  then  brought  together  and  the  edges  of 
the  iucisions  reunited. 

Knapp  (Fig.  139,  B).     Knapp  employed  the  following 
method  to  remove  an  epithelioma  occupying  the  inner  por- 


FlG.  141. 


m 


Ectropion.    Richet. 


tion  of  the  lower  eyelid,  the  free  border  of  which  was  in- 
volved. He  circumscribed  the  tumor  by  two  vertical  and 
two  horizontal  excisions  and  excised  it.  The  horizontal  iu- 
cisions were  then  prolonged  on  both  sides,  the  lower  external 
one  being  inclined  downward  so  as  to  make  the  base  of  the 
flap  broader,  the  two  flaps  dissected  up,  drawn  together  and 
united  by  their  vertical  edges. 


Fig.  142. 


~t$//j3Z&li 


Ectropion.    Jiurow. 


Burow  (Fig.  142).     The  loss  of  substance  is  made  tri- 
angular in  shape,  the  apex  directed  downward ;  the  base 


PLASTIC  OPERATIONS  ON  THE  FACE. 


297 


is  then  prolonged  horizontally  outward,  and  an  equal  and 
similar  triangle  marked  out  upon  the  upper  side  of  the  pro- 
longation. The  skin  contained  within  the  second  triangle 
is  then  excised,  and  the  irregular  flap  bounded  by  the  outer 
sides  of  the  two  triangles  and  the  prolongation  of  the  hori- 
zontal incision  dissected  outward  and  downward,  and  then 
moved  toward  the  median  line  until  it  covers  both  the  open 
spaces. 

It  is  not  necessary  that  the  two  triangular  spaces  should 
touch  at  one  corner ;  they  may  be  an  inch,  or  even  more, 
apart ;  but  they  must  of  course  be  connected  by  the  hori- 
zontal incision. 

Dieffenbach  (Fig.  143).  When  the  cicatrix  or  tumor  was 
large  DiefFenbach  gave  the  loss  of  substance  a  triangular 
shape,  the  apex  directed  downward.  He  prolonged  out- 
ward the  horizontal  incision  forming  the  base  of  the  tri- 
angle, and  carried  another  incision  downward  and  inward 
from  its  outer  extremity.  The  quadrilateral  flap  thus 
marked  out  was  dissected  up  and  carried  inward  to  cover 


Ectropion.    Dieffenbach. 


the  loss  of  substance.  The  gap  left  by  its  removal  was 
then  drawn  partly  together  with  sutures,  and  the  remainder 
left  to  granulate. 

Indian  Method  Sedillot  refers  the  first  blepharoplasty 
by  the  Indian  method  to  Von  Graefe  in  1809.  As  this  was 
previous  to  the  introduction  of  rhinoplasty  by  the  same 
method,  the  idea  was  probably  entirely  original  with  Von 
Graefe.  The  case  is  mentioned  in  his  Rhinoplastik,  1818, 
but  without  details.     The  flap  can  be  taken  from  the  fore- 


298 


OPERATIVE  SURGERY. 


head  or  cheek  ;  it  should  be  very  large  and  should  include 
the  subcutaneous  cellular  tissue.  Fricke,  of  Hamburg,  took 
a  vertical  flap  from  the  temporal  region  to  restore  the  upper 
eyelid. 

One  of  the  modifications  of  this  method,  intended  to  ob- 
viate the  necessity  of  dividing  the  pedicle,  is  showu  in  Fig. 
144,  A. 

Richet  (Fig.  144,  B).  The  lids  are  freed  by  two  in- 
cisions inclosing  all  the  cicatricial  tissue,  and  then  united 


Fig.  144. 


Ectropion.    A.  Modified  Indian  method.    B.  Richet. 


(blepharoraphy),  the  sutures  being  cut  long  and  their  ends 
fastened  upon  the  forehead.  Two  flaps  are  then  marked 
out  as  shown  in  the  figure,  the  external  one,  C,  raised  and 
used  to  cover  the  original  loss  of  substance,  and  the  inner 
one,  D,  used  to  fill  the  gap  occasioned  by  the  removal  of  0. 
Hasner  d'Artha  (Fig.  145)  employed  the  following 
method  in  a  case  where  a  tumor  occupied  the  commissure 
and  inner  portion  of  each  eyelid.  He  made  a  curved  in- 
cision, a,  beginning  at  the  border  of  the  upper  eyelid 
beyond  the  limit  of  the  tumor,  crossing  the  eyebrow  to  the 
forehead,  and  then  crossing  downward  to  terminate  near  the 
root  of  the  nose.  A  second  curved  incision,  c,  began  at  the 
same  point  as  the  first  and  was  carried  along  the  upper  and 
inner  edge  of  the  tumor  to  the  point  marked/.  A  third 
curved  incision,  e,  began  on  the  border  of  the  lower  lid 
beyond  the  limit  of  the  tumor  and  was  carried  along  the 
lower  margin  of  the  latter  to  the  point/.  A  fourth  curved 
incision,  gt  parallel  to  the  border  of  the  lower  lid,  was  car- 
ried from  the  point  outward  to  the  cheek. 


PLASTIC  OPERATIONS  ON  THE  FACE. 


299 


The  tumor  and  the  portion  of  the  lids  circumscribed  by 
the  incisions  e  and  e  were  then  removed,  and  each  of  the 
flaps  d  and  h  dissected  up  to  its  base.  The  former  was 
lowered,  the  latter  raised,  and  the  excess  of  each  cut  off. 
The  upper  border  of  the  flap  h  formed  the  free  border  of 


Fig.  145. 


Ectropion.    Hasner  d'Artha's  method. 


the  lower  lid,  and  the  lower  border  of  the  flap  d  formed 
the  free  border  of  the  upper  lid  aud  the  commissure  corre- 
sponded to  the  apex  of  the  flap  h.  The  skin  of  the  fore- 
head and  cheeks  was  mobilized  and  reunited  to  the  flaps 
(Dubrueil). 


Fig.  146. 


Ectropion.    Denonvilliers's  method  "  by  exchange." 

DenonviUiers' 's  method  "  by  exchange  "  (Fig.  146).  In 
a  case  of  ectropion  of  the  lower  lid,  with  deviation  of  the 
outer  angle  of  the  eye  downward,  DenonviUiers  used  the 


300  OPERATIVE  SURGERY. 

following  method  :  By  making  three  incisions  to  meet  in 
the  form  of  Z,  he  marked  out  two  adjoining  triangular 
flaps ;  one  of  them  included  the  outer  angle  of  the  eye,  the 
apex  of  the  other  was  situated  upon  the  forehead  just  above 
the  eyebrow.  He  then  dissected  up  the  flaps,  restored  the 
augle  of  the  eye  to  its  proper  position,  brought  the  upper 
flap  down  into  the  gap  made  by  the  lower  incision,  and  the 
lower  flap  up  into  that  made  by  the  upper  incision. 

Ectropion  due  to  excess  of  the  conjunctiva  may  be  treated 
by  cauterization  of  the  conjunctiva,  or  by  excision  of  a 
portion.  The  latter  operation  is  simple ;  a  fold  is  pinched 
up  with  forceps  and  excised  with  knife  or  scissors.  The 
edges  of  the  gap  may  then  be  brought  together  by  sutures 
or  left  to  granulate. 

2.  Entropion.  Canthojplasty  (q.  v.)  may  be  employed  to 
remedy  moderate  entropion,  especially  if  it  be  due  to  spasm 
of  the  orbicularis. 

Ligature  (Fig.  147),  proposed  by  Gaillard  to  remedy 
trichiasis,  is  equally  applicable  to  the  cure  of  entropion. 

Pig.  147. 


/ 
Entropion ;  ligature. 

A  transverse  fold  is  pinched  up,  and  a  needle  carrying  a 
stout  ligature  passed  through  its  base,  shaving  the  anterior 
surface  of  the  cartilage.  The  ligature  is  tied  and  allowed 
to  cut  through  the  skin.  The  resulting  linear  cicatrix 
maintains  the  lid  in  the  position  given  it  by  the  ligature. 

liau  has  modified  this  by  planing  several  ligatures  instead 
of  only  one 

Excision  or  cauterization  of  a  fold  of  the  shin  is  appli- 
cable to  cases  of  entropion  due  to  laxity  of  the  skin  of  the 


PLASTIC  OPERATIONS  ON  THE  FACE. 


301 


eyelid.  A  transverse  or  a  vertical  fold  is  pinched  up  quite 
near  to  the  margin  of  the  lid  aud  excised  ;  the  borders  of 
the  wound  are  united  by  sutures.  Instead  of  excision,  cau- 
terization of  the  strip,  preferably  with  sulphuric  acid,  is 
sometimes  used. 

Von  Graefe  (Fig.  148)  treated  a  case  of  spasmodic 
entropion  by  removal  of  a  triangular  piece  of  skin.  He 
made  a  cutaneous  incision  parallel  to  the  free  border  of  the 
lid,  and  about  a  line  from  it,  and  excised  a  triangular  cuta- 
neous flap,  the  base  of  which  occupied  the  median  portion 
of  the  first  incision.  The  sides  of  the  wound  left  by  the 
excision  of  the  triangular  piece  were  then  drawn  together 
with  sutures. 

For  spasmodic  entropion  of  the  upper  lid,  with  retraction 
of  the  tarsal  cartilage,  Von  Graefe  modified  the  operation 


Fig.  148. 


Fig.  149. 


Entropion— lower  lid.    Von  Graefe. 


Entropion— upper  lid.    Von  Graefe. 


as  follows  (Fig.  149) :  After  excision  of  the  triangular 
cutaneous  flap,  he  drew  the  sides  of  the  wound  apart,  divided 
the  orbicular  muscle  horizontally  near  the  edge  of  the  lid, 
and  drew  it  upward,  exposing  the  cartilage.  He  then  ex- 
cised a  triangular  piece  of  the  cartilage,  the  apex  being  at 
its  lower  border,  taking  care  not  to  include  the  conjunctiva 
in  the  dissection.  The  sides  of  the  cutaneous  wound  were 
then  drawn  together  with  three  sutures,  the  middle  one  of 
which  included  also  the  sides  of  the  gap  left  in  the  cartilage. 
Excision  of  a  Portion  of  the  Orbicularis.  Key  cured  a 
case  of  spasmodic  entropion  by  excising  a  few  fibres  of  the 
orbicular  muscle.     He  made  an  incision  through  the  skin 

14 


302  OPERATIVE  SURGERY. 

parallel  to  and  near  the  free  border  of  the  lid,  exposed  the 
muscle,  and  removed  a  bundle  of  fibres  from  its  central 
margin.  It  is  well  to  combine  this  with  removal  of  a  hori- 
zontal  strip  of  skin. 

Division  or  Resection  of  the  Tarsal  Cartilage.  When 
the  entropion  is  caused  or  maintained  by  shortening  or  in- 
curvation of  the  tarsal  cartilage,  the  operation  must  be 
directed  to  the  removal  of  this  cause. 

Vertical  division  at  one  or  two  points  of  the  entire  thick- 
ness of  the  lid  has  been  employed.  After  having  been 
divided,  the  border  of  the  lid  is  held  in  its  proper  position 
by  ligatures  passed  through  it  and  fasteued  to  the  forehead 
(upper  lid)  or  cheek  (lower  lid),  while  the  wound  fills  and 
heals  by  granulation. 

A  horizontal  incision  through  the  conjunctiva  from  one 
vertical  incision  to  the  other  makes  it  easier  to  turn  the  lid 
out  and  hold  it  in  place. 

Longitudinal  Tarsotomy  (Ammon).  The  eyelid  having 
been  turned  out,  a  knife  is  passed  through  it  from  the  con- 

Fig.  150. 


Knapp's  modification  of  Desmarres's  forceps. 

junctival  side,  quarter  of  an  inch  from  the  border,  and  on 
a  line  with  the  lachrymal  point,  and  an  incision  made  parallel 
with  the  border  nearly  to  the  outer  angle.  A  longitudinal 
strip  of  skin  is  then  excised,  and  the  edges  of  the  gap  left 
by  the  excision  are  drawn  together.  By  this  means  the 
free  border  of  the  lid  is  drawn  away  from  the  surface  of 
the  eye,  turning  upon  the  longitudinal  incision  as  upon  a 
hinge. 

Excision   of  part  of  the    Cartilage   (Streatfeild),   (Fig. 
151). 


PLASTIC  OPERATIONS  ON  THE  FACE.  303 

The  eyelid  is  fixed  with  Desrnarres's  forceps  (Fig.  150), 
the  flat  blade  against  the  conjunctiva,  and  an  incisiou  made 
parallel  to  the  border  of  the  lid  at  the  distance 
of  one  line  from  it,  and  carried  to  a  depth  suffi-  FlG-  15L 
cient  to  expose  the  bulbs  of  the  eyelashes.  The 
surgeon,  raising  the  edge  of  the  skin,  passes 
around  the  bulbs  to  the  tarsal  cartilage,  and  then 
makes  a  second  incision  at  a  greater  distance 
from  the  border  of  the  lid  than  the  first  one  was, 
meeting  the  first  at  its  two  extremities  and  in- 
closing with  it  an  oval  strip  of  skin.  These  two 
incisions  are  carried  into  the  cartilage,  circum- 
scribing a  longitudinal  wedge-shaped  strip,  the 
apex  of  which  reaches  nearly  to  the  conjuncti- 
val side  of  the  cartilage.  The  wound  is  left  to 
heal  by  granulation,  with  the  expectation  that  the  con- 
traction of  the  cicatrix  will  overcome  the  entropion. 

3.  Symblepharon.  When  the  adhesion  between  the  two 
layers  of  the  conjunctiva  is  incomplete,  that  is,  when  it 
does  not  extend  to  the  bottom  of  the  sulcus  between  the  lid 
and  eyeball,  it  is  sufficient  to  throw  a  ligature  around  it. 
After  the  ligature  has  cut  through,  the  tabs  are  succes- 
sively excised,  and  the  borders  of  each  wound  drawn  to- 
gether or  left  to  heal  by  granulation.  To  avoid  reunion 
of  the  surfaces,  the  second  tab  should  not  be  removed  until 
after  the  wound  left  by  the  removal  of  the  first  has  healed. 

When  the  adhesion  is  complete,  but  not  broad,  a  thread 
or  silver  wire  may  be  passed  through  its  base  and  tied 
loosely  around  it.  After  the  hole  made  by  the  wire  has 
cicatrized  the  adhesion  is  divided.  The  narrow  line  of  cica- 
trix left  at  the  bottom  of  the  fold  by  the  wire  favors  the 
separate  healing  of  the  two  sides  of  the  incision. 

Arlt's  Method.  A  thread  is  passed  through  the  fold 
close  to  the  cornea,  and  the  symblepharon  dissected  awav 
from  the  eyeball.  Each  end  of  the  thread  is  then  attached 
to  a  needle  and  passed  through  the  lid  from  within  outward 
at  the  bottom  of  the  wound.  By  drawing  upon  the  thread 
and  tying  it  outside  the  lid  the  symblepharon  is  folded 
upon  itself  and  its  point  fixed  at  the  bottom  of  the  sulcus. 
The  edges  of  the  wound  on  the  eyeball  are  then  drawn 


304 


OPERATIVE  SURGERY. 


together  with  sutures,  the  conjunctiva  being  loosened  by 
dissection,  if  necessary. 

Teak's  Method  (Figs.  152,  153,  154).  This  symble- 
pharon is  separated  from  the  ball  of  the  eye  by  an  incision 
along  the  line  of  its  union  with  the  cornea,  and  dissected 
down  to  the  bottom  of  the  fold  as  in  Arlt's  operation,  its 


Fir,.  152. 


Fig.  153. 


Symblepharon. 


B,  C.    The  flaps. 


apex,  however,  being  left  upon  the  cornea.  Two  long, 
narrow  conjunctival  flaps,  B  and  C,  are  then  dissected  up 
on  opposite  sides  of  the  eyeball,  their  bases  directed  toward 
the  symblepharon,  their  borders  parallel  to  that  of  the 
cornea.  These  flaps  should  not  include  the  subconjunc- 
tival tissue.     The  inner  flap  B  is  brought  down  and  fast- 


FlG.  154. 


Flaps  in  place. 

ened  to  the  denuded  surface  of  the  eyelid,  the  outer  flap  C 
covers  that  of  the  eyeball.  They  arc  fastened  in  place  by 
means  of  fine  sutures,  and  the  edges  of  the  gaps  left  by 
their  removal  brought  together  in  the  same  manner. 

Ledentu's    Operation.      Where    one    lid    was   adherent 
throughout  its  entire  length,  Ledentu  divided  the  adhesion 


PLASTIC  OPERATIONS  ON  THE  FACE.  305 

to  a  depth  equal  to  that  of  the  normal  fold,  dissected  a  long 
conjunctival  flap  from  the  other  half  of  the  eye,  leaving  it 
adherent  at  both  ends,  brought  it  down  across  the  cornea, 
and  applied  it  to  the  raw  surface  left  on  the  eyeball  by  the 
division  of  the  adhesion.  This  flap  should  beat  least  one- 
third  of  an  inch  broad. 

4.  Pterygion.  Excision.  The  pterygion  is  pinched  up 
with  forceps,  a  knife  passed  flatwise  under  it  close  to  the 
cornea,  and  the  portion  of  the  growth  which  corresponds  to 
the  latter  shavecl  off.  The  edges  of  the  conjunctival  wound 
are  then  drawn  together  with  sutures. 

Scissors  may  be  used  instead  of  the  knife;  in  that  case 
the  incision  must  begin  at  the  point  of  the  growth. 

Ligature,  Szokalski  (Fig.  155).  A  thread  is  passed 
under  the  pterygion  by  means  of  twosmall  curved  needles, 

Fig.  155. 


Pterygion  ;  ligature. 


as  shown  in  Fig.  155.  The  thread  is  cut  close  to  the 
needles,  and  thus  made  to  furnish  three  ligatures,  one  at 
each  end,  encircling  the  growth  at  right-angles  to  its  long 
axis,  and  one  in  the  middle,  encircling  its  implantation  upon 


306  OPERATIVE  SURGERY. 

the  sclerotic.     The  ligatures  are  tied  tightly,  and  the  in- 
closed portion  falls  in  a  few  days. 

5.  Trichiasis.  Temporary  removal  of  the  deviated  lashes 
is  seldom  effectual.  Permanent  removal  by  destruction  of 
their  bulbs,  or  excision  of  the  border  of  the  lid,  is  now  con- 
sidered unjustifiable.  The  direction  of  the  lashes  may  be 
changed  by  operation  upon  the  lid.  The  retraction  follow- 
ing excision  of  an  oval  strip  of  skin,  or  the  use  of  ligatures 
as  in  entropion,  is  sometimes  sufficient,  but  it  may  be  neces- 
sary to  act  more  directly  upon  the  lashes.  Simple  splitting 
of  the  external  can  thus  may  be  sufficient. 

Von  Graefe's  Method.  An  incision  is  made  along  the 
free  border  of  the  lid  on  the  conjunctival  side  of  the  devi- 
ated lashes.  From  each  end  of  this  a  vertical  incision  is 
next  made  through  the  free  border  and  the  skin.  The  flap 
thus  circumscribed  and  containing  the  lashes  is  dissected 
up  a  short  distauce.  It  is  then  easy  to  fasten  it  with  sutures 
in  such  a  position  that  the  lashes  can  no  longer  touch  the 
eyeball. 

Anagnostahis  made  a  cutaneous  incision  parallel  to  the 
border  of  the  upper  lid  and  one-eighth  of  an  inch  from  it, 
exposed  the  orbicular  muscle  by  drawing  the  skin  up,  and 
excised  that  portion  of  it  which  corresponded  to  the  upper 
part  of  the  tarsal  cartilage.  The  lower  edge  of  the  cuta- 
neous incision  was  then  drawn  up  and  fixed  to  the  fibro- 
cellular  layer  covering  the  cartilage  by  means  of  three  or 
four  sutures,  which  were  then  allowed  to  cut  themselves  out. 


PART  VII. 

SPECIAL  OPERATIONS. 


CHAPTER    I. 
OPERATIONS  UPON  THE  EYE  AND  ITS  APPENDAGES. 

In  most  operations  upon  the  eye  the  lids  should  be  held 
open  by  an  eye-speculum  (Fig.  156),  and  the  eyeball  fixed 

Fig.  156. 


Eye-speculum. 

by  pinching  up  a  fold  of  the  conjunctiva  with  toothed  for- 
ceps. 

The  instillation  of  a  few  drops  of  a  4  per  cent,  solution 
of  the  hydrochlorate  of  cocaine  under  the  lids  will  make 
most  operations  painless,  but  the  sensitiveness  of  the  iris  is 
not  thereby  abolished. 

THE   CORNEA. 

Removal  of  a  Foreign  Body.  When  the  foreign  body  has 
penetrated  to  only  a  slight  depth,  it  may  be  easily  removed 


308  OPERATIVE  SURGERY. 

with  the  point  of  a  knife  or  fine  forceps ;  but,  if  it  lies  so 
near  the  posterior  surface  of  the  cornea  that  there  is  danger 
of  forcing  it  through  into  the  anterior  chamber  by  the  efforts 
made  for  its  extraction,  a  lance-shaped  knife  must  be  en- 
tered very  obliquely  and  passed  behind  it,  between  the 
layers  of  the  cornea  if  there  is  sufficient  space,  otherwise 
within  the  anterior  chamber. 

If  the  foreign  body  falls  into  the  anterior  chamber,  not- 
withstanding these  efforts  to  prevent  it,  the  surgeon  must 
wait  uutil  the  aqueous  humor  has  reaccumulated,  and  then 
make  an  incision  three  or  four  millimetres  in  length  at  the 
lower  portion  of  the  periphery  of  the  cornea,  in  the  hope 
that  the  foreign  body  will  be  washed  out  during  the  flow  of 
the  liquid. 

Puncture  of  the  Cornea.  This  may  be  made  with  a  broad 
needle  or  a  well-worn  Beer's  knife.  It  is  advisable  to  em- 
ploy anaesthesia,  and  to  steady  the  eyeball  with  fixation 
forceps.  The  surgeon  stands  behind  the  patient,  raises  the 
upper  lid,  and  fixes  it  against  the  margin  of  the  orbit  with 
two  fingers  of  his  left  hand,  which  also  rest  against  the 
inner  side  of  the  eyeball  and  prevent  it  from  rotating 
inward.  The  needle  or  knife  is  then  entered  a  little  in 
front  of  the  edge  of  the  cornea  at  the  outer  side.  Its  di- 
rection must  be  sufficiently  oblique  to  avoid  injury  to  the 
iris,  and  not  so  much  so  that  the  instrument  will  remain 
between  the  layers  of  the  cornea  and  fail  to  penetrate  to 
the  anterior  chamber.  By  partly  withdrawing  the  instru- 
ment aud  twisting  it  slightly,  the  incision  is  made  to  gape 
and  allow  the  escape  of  the  liquid  ;  or  a  fine  blunt  probe 
may  be  passed  into  the  incision  after  entire  withdrawal  of 
the  needle.  Subsequent  tappings  are  effected  by  reopening 
the  original  wound  with  the  probe.  Figure  157  represents 
a  combined  needle  and  probe.  The  needle  is  provided  with 
a  shoulder  to  prevent  its  introduction  to  too  great  a  depth. 

Evisceration  of  the  Globe  for  Staphyloma.  The  sclerotic 
is  incised  with  a  Beer's  knife  just  in  front  of  the  insertion 
of  the  external  rectus  ;  into  the  opening  is  passed  one  blade 
of  a  pair  of  small  blunt-pointed  scksors,  and  the  anterior 
portion  of  the  globe  is  cut  away,  with  the  lens  and  all  the 


SPECIAL  OPERATIONS 


309 


Fig.  157 


Flu. 158 


Stop  needle  and  probe  for 
puncturing  the  cornea. 


Beer's  knife. 


14* 


310  OPERATIVE  SURGERY. 

vitreous  humor.     The  wound  is  then  closed  with  catgut 
sutures  passed  through  the  conjunctiva  alone. 


THE    IRIS. 

Iridotomy.  Incision  of  the  iris  may  be  performed  for 
the  purpose  of  establishing  an  artificial  pupil.  As  its  suc- 
cess depends  upon  the  retraction  of  the  divided  fibres,  it 
should  be  undertaken  only  when  their  contractility  is  not 
interfered  with  by  too  extensive  adhesions,  or  has  not  been 
destroyed  by  disease.  The  more  commou  lesions  to  which 
the  operation  is  applicable  are  central  opacity  of  the  cornea, 
occlusion  of  the  pupil,  and  excessive  prolapse  of  the  iris 
after  removal  of  a  cataract ;  but  the  danger  of  injury  to 
the  lens  is  so  great  that  the  operation  is  practically  restricted 
to  the  class  of  cases  last  mentioned. 

The  best  place  for  an  artificial  pupil  is  in  the  lower  inner 
quarter  of  the  iris,  the  second  best  in  the  lower  outer 
quarter.  As  the  portion  of  the  cornea  traversed  by  the 
knife  or  needle  is  likely  to  become  more  or  less  opaque  in 
consequence,  the  incision  in  it  should  be  made  as  far  as 
possible  from  the  point  where  the  pupil  is  to  be  created. 

Simple  Incision.  Cheselden,  who  was  the  first  to  per- 
form this  operation,  entered  a  narrow-bladed  knife  through 
the  sclerotic  just  anterior  to  the  insertion  of  the  external 
rectus,  the  point  directed  toward  the  centre  of  the  globe 
of  the  eye.  After  the  point  had  penetrated  to  the  depth 
of  one-eighth  of  au  inch  it  was  directed  forward,  passed 
through  the  iris  to  the  anterior  chamber  and  transversely 
across  the  latter,  its  edge  looking  backward.  By  pressing 
the  edge  against  the  iris  and  withdrawing  it  a  horizontal 
incision  was  made  in  that  membrane. 

Bowman  punctured  the  cornea  midway  between  its  centre 
and  external  border,  passed  a  narrow  blunt-pointed  knife 
through  the  puncture  into  the  anterior  chamber,  and  thence 
through  the  pupil  to  the  posterior  surface  of  the  inner  half 
of  the  iris,  which  he  then  divided  by  cutting  forward.  The 
danger  of  injury  to  the  cornea  during  the  last  step  of  the 
operation  is  very  great. 


SPECIAL  OPERATIONS.  311 

Bell1  uses  a  double-edged  needle  which  is  "  introduced 
through  the  cornea  near  its  margin ;  on  arriving  at  the 
place  where  the  pupil  ought  to  be,  one  edge  is  drawn 
against  the  iris  and  divides  it  transversely,  if  possible, 
without  injuring  the  lens." 

Wecker  proposes  simple  iridotomy  and  double  iridotomy  ; 
the  former  in  cases  of  central  opacity  of  the  cornea  or  lens, 
the  latter  when  the  pupil  has  become  obliterated  after  re- 
moval of  a  cataract.  He  uses  a  small  lance-shaped  knife 
with  a  shoulder,  straight  or  bent  upon  the  flat,  and  a  pair 
of  forceps-scissors. 

Simple  Iridotomy  (Wecker).  The  knife  is  entered  mid- 
way between  the  centre  and  border  of  the  cornea  on  the 
side  opposite  to  that  on  which  the  pupil  is  to  be  made.  As 
soon  as  the  cornea  has  been  perforated  the  knife  is  with- 
drawn and  the  forceps-scissors  passed  through  the  wound 
to  the  further  border  of  the  pupil,  where  they  are  opened 
and  one  of  the  blades  passed  behind,  the  other  in  front,  of 
the  iris.  By  closing  them  sharply  the  circular  fibres  are 
divided  from  the  margin  of  the  pupil  toward  the  periphery 
of  the  iris.  The  scissors  are  then  withdrawn,  the  iris  re- 
placed if  it  engages  in  the  wound,  a  few  drops  of  a  solution 
of  atropine  placed  between  the  eyelids,  and  a  compress  ap- 
plied. 

Double  Iridotomy  (Wecker).  The  knife  is  passed  per- 
pendicularly through  the  cornea  and  iris  one  millimetre 
from  the  edge  of  the  conjunctiva,  on  the  side  toward  which 
the  obliterated  pupil  has  been  retracted ;  its  point  is  then 
made  to  pass  along  the  posterior  surface  of  the  iris  until 
arrested  by  its  shoulder,  when  it  is  withdrawn  slowly.  The 
forceps-scissors  are  next  introduced  through  the  incision, 
and  one  blade  passed  behind  and  the  other  in  front  of  the 
iris  for  a  distance  of  one-quarter  of  an  inch  or  a  little  less. 
Two  successive  sections  of  the  iris  are  then  made,  inclosing 
a  triangular  flap,  the  apex  of  which  is  directed  toward  the 
incision  in  the  cornea.  The  pupil  is  formed  by  the  retrac- 
tion of  this  flap. 

Iridectomy.  Excision  of  a  portion  of  the  iris  may  be 
employed  for  the  purpose  of  creating  an  artificial  pupil 

1  Manual  of  Surgical  Operations,  3d  edition,  p.  162. 


312 


OPERATIVE  SURGERY. 


(optical  iridectomy),  or  for  the  relief  of  tension  in  glaucoma 
or  irido-choroiditis  (autiphlogistic  iridectomy),  or  as  a  pre- 
liminary to  the  removal  of  a  cataract.  The  size  of  the 
portion  excised  is  determined  by  the  length  and  position  of 
the  line  of  the  incision  on  the  posterior  surface  of  the 
cornea ;  the  nearer  this  is  to  the  margin  of  the  cornea  the 
larger  will  be  the  portion  of  the  iris  removed.  In  antiphlo- 
gistic iridectomy,  therefore,  when  the  entire  breadth  of  the 
iris  from  the  pupil  to  its  outer  margin  should  be  removed, 
the  knife  must  be  entered  one  millimetre  outside  of  the 
clear  portion  of  the  cornea ;  in  optical  iridectomy,  on  the 
other  hand,  the  excised  portion  should  be  small  and  the 
knife  should  be  entered  within  the  margin  of  the  cornea. 
In  antiphlogistic  iridectomy  at  least  one-fourth  of  the  iris 
should  be  removed,  the  piece  being  taken  from  the  upper 
segment  in  order  that  the  loss  may  be  hidden  by  the  upper 
eyelid.  In  optical  iridectomy  the  pupil  should  be  made  on 
the  inner  side  of  the  lower  segment  unless  corneal  opacities 
are  in  the  way. 


Fig.  159. 


Fig.  160. 


Operation  for  Antiphlogistic  Iridectomy.  The  instru- 
ments required  area  lance-shaped  knife,  straight  (Fig.  159) 
or  bent  (Fig.  100),  iridectomy  forceps  (Figs.  161  and  162), 
and  scissors  curved  upon  the  flat  (Fig.  163). 

The  patient  having  been  anaesthetized  and  placed  in  a 


SPECIAL  OPERATIONS. 


313 


recumbent  posture,  the  surgeon  takes  such  a  position  in 
front  of  or  behind  him  as  will  facilitate  the  making  of  the 


Fig.  161. 


Fig.  162. 


Fig.  163. 


ffl 


Fig.  164. 


Iridectomy.    Incision  of  cornea. 


first  iucisiou.     The  eye-speculum  and  fixation  forceps  hav- 
ing been  applied,  the  latter  immediately  opposite  the  poiut 


314 


OPERATIVE  SURGERY. 


of  puncture,  the  knife  is  introduced  perpendicularly  to  the 
surface  of  the  sclerotic  one  millimetre  outside  of  the  margin 
of  the  coruea  and  passed  steadily  in  until  its  point  has 
entered  the  anterior  chamber  at  its  very  rim ;  its  direction 
is  then  changed  aud  it  is  carried  along  the  anterior  surface 
of  the  iris  uutil  its  point  reaches  the  contre  of  the  pupil,  or 
until  the  length  of  the  incision  is  considered  sufficient  (Fig. 
164).  By  inclining  the  point  of  the  knife  to  each  side,  the 
length  of  the  incision  in  the  posterior  surface  of  the  cornea 
may  be  made  equal  to  that  of  the  anterior  surface. 

The  knife  is  then  withdrawn  and  the  aqueous  humor 
allowed  to  run  off  very  slowly  in  order  that  the  relief  of 
intra-ocular  pressure  may  not  be  so  sudden  as  to  lead  to 
congestion  and  hemorrhage. 

If  the  iris  does  not  now  present  in  the  wound  the  iridec- 
tomy forceps  must  be  introduced  closed  as  far  as  to  the 
margin  of  the  pupil,  which  is  then  seized  and  drawn  out 
gently  through  trie  incision.  An  assistant  then  cuts  oft 
with  the  curved  scissors  all  the  protruding  portion  of  the 
iris  close  to  the  lips  of  the   wound  (Fig.  165).     Or  the 

fixation  forceps  may  be  con- 

FlG- 165-  tided  to  the  assistant  before 

the  introduction  of  the  iri- 


FlG.  166. 


Tyrrell's  hook. 

dectomy  forceps,  and  the 
surgeon  left  free  to  use  the 
scissors  himself.  Instead  of 
the  iridectomy  forceps,  Tyr- 
rell's hook  (Fig.  166)  may 
be  used  to  draw  the  iris  out  through  the  incision.  It  must 
be  introduced  upon  its  side,  hooked  around  the  margin  of 
the  pupil,  and  then  its  point  must  be  turned  toward  the 
cornea  and  away  from  the  centre  of  the  eyeball  so  that  it 
will  not  catch  upon  the  posterior  edge  of  the  incision  during 
its  withdrawal. 

If  any  hemorrhage  takes  place  into  the  anterior  chamber 


I  rldectomy.    Excision  of  the  iris. 


SPECIAL  OPERATIONS.  315 

the  escape  of  the  blood  before  coagulation  should  be  favored 
by  separating  the  lips  of  the  incision  with  a  curette,  and 
making  gentle  pressure  upon  the  eyeball.  The  edges  of 
the  iris  must  be  carefuly  replaced  with  a  spatula  and  not 
left  included  in  the  corneal  wound. 

Iridesis,  or  displacement  of  the  pupil  by  ligature.  Crit- 
chett,1  the  inventor  of  this  operation,  claims  that  by  it  the 
size,  form,  and  direction  of  the  pupil  can  be  regulated  to  a 
nicety,  and  its  mobility  preserved.  It  is  applicable  to  nu- 
merous groups  of  cases  in  which  the  natural  pupil,  or  even 
a  part  thereof,  is  movable,  and  has  a  free  edge ;  but  the 
simplest  class  is  that  of  central  opacity  of  the  cornea,  in 
which  it  is  only  required  that  the  natural  pupil  should  be 
moved  slightly  to  one  side,  so  as  to  bring  it  opposite  the 
transparent  part  of  the  cornea.  It  has  also  been  used  in 
cases  of  conical  cornea,  to  change  the  shape  of  the  pupil  to 
that  of  a  slit ;  and  in  a  case  where  the  pupil  had  been  ren- 
dered very  small  and  narrow  by  broad  synechias,  Critchett 
made  it  large  and  almost  circular  by  drawing  its  sides  apart 
at  nearly  opposite  points. 

The  operation  is  performed  as  follows : 

An  opening  is  made  with  a  broad  needle  through  the 
margin  of  the  cornea  close  to  the  sclerotic,  and  just  large 

Fig.  167. 


Iridesis. 


enough  to  admit  the  canula  forceps.     A  small  portion  of  the 
iris  near  but  not  close  to  its  ciliary  attachment  is  seized  and 

1  Ophthalmic  Hospital  Reports,  vol.  i.  p.  220. 


316  OPERATIVE  SURGERY. 

drawn  out  to  the  extent  considered  sufficient  for  the  pro- 
posed enlargement  of  the  pupil ;  a  piece  of  fine  floss  silk, 
previously  tied  in  a  small  loop  round  the  cauula  forceps,  is 
slipped  down,  and  carefully  tightened  around  the  portion  of 
iris  made  to  prolapse,  so  as  to  include  and  strangulate  it 
(Fig.  167).  This  manoeuvre  is  best  accomplished  by  hold- 
ing each  end  of  the  silk  with  a  pair  of  small  broad-bladed 
forceps,  bringing  them  exactly  to  the  spot  where  the  knot 
is  to  be  tied,  and  then  drawing  it  moderately  tight.  The 
small  portion  of  the  iris  included  in  the  ligature  speedily 
shrinks,  leaving  the  little  loop  of  silk,  which  may  be  re- 
moved ou  the  second  day. 

If  it  is  desired  to  make  the  pupil  extend  to  the  periphery 
of  the  iris,  the  margin  of  the  pupil  must  be  seized  with 
the  forceps  and  drawn  out  through  the  incision.  In  this 
case  Soelberg  Wells  prefers  a  blunt  hook  to  the  canula 
forceps. 

Corelysis,  or  rupture  of  adhesions  uniting  the  margin  of 
the  pupil  and  the  lens.  The  operation  was  first  performed 
by  Streatfeild,  as  follows:1  He  punctured  the  cornea  with 
a  broad  needle  on  the  outer  side  near  its  margin,  passed  his 
spatula  (Fig.  168)  along  the  anterior  surface  of  the  iris  to 
the  pupil,  engaged  the  adhesions  in  the  notch  on  the  edge 
of  the  spatula,  and  tore  them.  When  the  entire  margin  of 
the  pupil  was  adherent,  he  passed  the  needle  along  the  sur- 

FiG.  168. 


Streatfeild's  spatula  hook. 

face  of  the  iris,  across  the  pupil  to  its  opposite  margin,  and 
cut  the  adhesions  at  that  point.  Then  withdrawing  the 
knife,  he  passed  the  spatula  through  the  hole  thus  made, 
and  easily  broke  up  the  remaining  adhesions.  When  the 
adhesions  were  too  strong  to  be  broken  with  the  spatula, 
he  used  the  canula  scissors.  A  few  drops  of  a  solution  of 
atropine  should  be  applied  to  the  eye,  both  before  and 
after  the  operation. 

1  Ophthalmic  Hospital  Kurorts,  vol.  i.  p.  (>. 


SPECIAL  OPERATIONS.  317 


OPERATIONS    UNDERTAKEN    FOR    THE    RELIEF    OF 
CATARACT. 

A  cataract  is  an  opacity  of  the  crystalline  lens,  or  of  its 
capsule,  or  of  both :  the  former  being  much  the  more  common 
variety.  It  may  be  hard,  soft,  or  semiliquid,  and  its  con- 
dition, in  this  respect,  has  an  important  bearing  upon  the 
choice  of  a  method  of  operation.  The  lens  is  composed  of 
a  solid  nucleus  and  a  soft  cortex ;  the  whole  lying  free 
within  the  capsule  which  is  itself  attached  to  the  vitreous 
humor.  In  consequence  of  the  absence  of  adhesions  be- 
tween the  lens  and  the  capsule,  moderate  pressure  is  suffi- 
cient to  force  out  the  former  after  the  latter  has  been 
divided. 

In  operating  upon  a  cataract,  the  patient  should  be 
recumbent :  cocaine  anaesthesia  is  sufficient  except  with 
young  children  or  unruly  patients,  when  ether  may  be 
necessary.  The  other  eye  should  be  covered  with  a  band- 
age, unless  its  sight  is  entirely  lost ;  and  an  eye-speculum 
may  be  used  to  keep  the  lids  apart,  if  the  services  of 
a  trained  assistant  cannot  be  had.  The  objection  to  a  spec- 
ulum is  that  it  is  somewhat  in  the  way  of  the  knife,  cannot 
be  removed  promptly  enough,  and  is  apt  to  make  dangerous 
pressure  upon  the  eye.  If  used,  the  screw  of  the  instrument 
should  be  loosened  as  soon  as  the  incision  has  been  made. 
A  few  drops  of  a  solution  of  atropine  should  be  placed 
under  the  lids  a  short  time  before  the  operation. 

The  methods  of  operation  may  be  classified  as: 

Depression  or  couching  ; 

Division,  discission,  or  solution  ; 

Extraction ; 

Operation  for  secondary  cataract. 

Depression  or  couching,  which  was  the  original  and,  for 
many  years,  the  only  method  of  removing  cataract,  is  now 
universally  abaudoned,  on  account  of  the  danger  that  the 
displaced  lens  may  set  up  inflammation  of  the  eye  by  con- 
tact with  the  other  parts,  especially  the  iris  and  ciliary  pro- 
cesses, and  thus  cause  total  loss  of  sight.  Soelberg  Wells 
states  that  about  fifty  per  cent,  of  the  eyes  thus  operated 


318 


OPERATIVE  SURGERY. 


upon  have  been  lost  by  chronic  irido-choroiditis.  The 
operation  will  be  described,  however,  for  the  sake  of  ref- 
erence. If  the  puncture  is  made  in  the  sclerotic,  the  ope- 
ration is  called  scleronyxis  ;  if  in  the  cornea,  keratonyxsis. 

Scleronyxis.  A  curved  couching  needle  (Fig.  169),  its 
convexity  turned  upward,  is  passed  through  the  sclerotic  on 
the  temporal  side  about  four  millimetres  from  the  margin 
of  the  cornea,  aud  three  millimetres  below  the  horizontal 
diameter  of  the  eye.  Its  convexity  is  then  turned  forward, 
and  the  needle  carried  behind  and  parallel  to  the  iris,  across 
to  the  upper  and  inner  margin  of  the  pupil  (Fig.  170),  when 
the  handle  is  lightly  tilted  upward,  and  the  lens  slowly 
depressed  by  the  concave  surface  of  the  needle.  After  hold- 
ing it  in  place  for  a  moment,  the  needle  is  slightly  rotated 
to  disentangle  its  poiut,  and  withdrawn. 

Some  authors  recommeud  that  the  anterior 
capsule  should  be  formally  divided  horizon- 
tally or  vertically  before  the  lens  is  depressed. 


Fig.  170. 


Depressing  cataract. 

Ke?-atonyxis.  The  needle  is  passed  through 
the  cornea  a  little  below  its  horizontal  diam- 
eter, and  midway  between  its  centre  and  mar- 
gin, and  carried  backward  and  inward, 
through  the  pupil  to  the  lens,  which  is  then 
Couching  needle,    depressed  as  before. 

In  the  variety  of  depression  called  reclina- 
tion,  the  upper  edge  of  the  lens  is  rotated  backward  about 
its  transverse  axis  at  the  same  time  that  it  is  depressed,  so 
that  its  anterior  becomes  its  superior  surface. 


SPECIAL  OPERATIONS. 


319 


Fig.  172. 


Division,  Discission,  or  Solution.  The  object  of  this 
operation  is  to  tear  open  the  anterior  capsule  with  a  fine 
needle,  and  by  thus  bringing  the  aqueous  humor  into  con- 
tact with  the  lens  to  promote  the  gradual  softening  and 
absorption  of  the  latter.  The  selection  of 
the  term  discission  was  made  in  consequence 
of  an  erroneous  impression,  that  the  more 
completely  the  lens  was  broken  up  at  first 
the  more  rapidly  would  the  work  of  absorp- 
tion go  on,  and  surgeons,  therefore,  tried  to 
cut  the  whole  lens  into  fragments.  Expe- 
rience has  since  shown  that  in  most  cases 
the  absorption  must  be  gradual  and  the 
operation  frequently  repeated,  only  a  small 
amount  of  the  substance  of  the  lens  being 


Fig.  171. 


Bowman's  fine  stop  needle. 

allowed  to  come  into  contact  with  the  aque- 
ous humor  on  each  occasion.  If  the  lens  is 
all  broken  up  at  once,  the  numerous  frag- 
ments swell  and  act  as  foreign  bodies  in  the 
aqueous  humor,  and  set  up  inflammation 
in  the  iris  and  cornea,  with  immediate  ar- 
rest of  the  process  of  absorption.  This 
operation  is  more  especially  indicated  in  the 
cortical  cataract  of  children  and  of  young 
persons  up  to  the  age  of  twenty  or  twenty- 
five  years,  also  in  those  forms  of  lamellar  cataract  in  which 
the  opacity  is  too  extensive  to  allow  of  much  benefit  being 
derived  from  an  artificial  pupil.     After  the  age  of  thirty- 


Hays's  knife 
needle. 


320  OPERATIVE  SURGERY. 

five  or  forty,  absorption  is  much  slower,  and  the  iris  much 
more  irritable. 

There  are  two  methods  of  performing  the  operation  ;  in 
one  the  needle  is  passed  through  the  cornea,  in  the  other 
through  the  sclerotic. 

Division  through  the  Cornea.  The  pupil  is  widely  di- 
lated with  atropine,  the  eyelids  drawn  apart  by  an  assistant, 
or  fixed  with  the  eye  speculum,  and  a  fold  of  conjunctiva 
on  the  inner  side  of  the  eye  seized  with  the  fixation  forceps. 
A  fine  spear-shaped  needle  with  a  shoulder  (Fig.  171)  is 
passed  through  the  outer  lower  quadrant  of  the  cornea, 
almost  perpendicularly  to  its  surface  at  a  point  well  within 
the  dilated  pupil,  so  that  the  iris  shall  not  be  touched  by 
the  needle.  One  or  more  incisious,  according  to  the  effect 
desired,  are  then  made  in  the  anterior  capsule  of  the  lens, 
the  needle  withdrawn,  and  a  compressive  bandage  applied. 
The  operation  may  be  repeated  as  soon  as  all  redness  and 
irritability  of  the  eye  have  disappeared. 

Division  through  the  Sclerotic  (Hays1).  The  patient  hav- 
ing been  prepared  as  before,  the  knife-needle  (Fig.  172), 
with  its  cutting  edge  upward,  is  passed  through  the  sclerotic 
at  a  point  on  its  transverse  diameter  three  or  four  milli- 
metres from  the  temporal  margin  of  the  cornea,  and  perpen- 
dicularly to  the  surface  of  the  eyeball.  Its  direction  is  then 
changed  and  its  point  carried  between  the  iris  and  lens  to 
the  opposite  margin  of  the  pupil.  If  it  encounters  and 
penetrates  the  lens  on  the  way,  it  will  probably  dislocate  it, 
in  which  case  extraction  should  be  at  once  performed ;  if 
the  needle  is  pushed  into  the  lens  without  dislocating  it,  the 
instrument  should  be  withdrawn  until  its  point  is  free,  and 
then  pushed  on  again  in  a  better  direction. 

This  being  accomplished,  the  edge  of  the  knife  is  turned 
back  against  the  centre  of  the  lens,  and  a  free  incision  made 
by  withdrawing  it  a  short  distance,  while  pressing  its  edge 
firmly  against  the  cataract. 

In  order  to  expedite  the  cure,  Wells  thinks  it  is  a  good 
plan  to  combine  division  with  extraction,  aud  remove  the 
whole  cataract  by  a  linear  incision  after  it  has  been  softened 
by  contact  with  the  aqueous  humor.     In  children  this  may 

1  American  Journal  of  Medical  Sciences,  July,  1855,  p.  81. 


SPECIAL  OPERATIONS. 


321 


be  done  within  a  week  after  the  division.  The  same  pro- 
ceeding may  be  employed  in  cases  of  partial  cataract,  the 
transparent  portion  of  the  lens  being  made 
opaque  and  softened  by  the  introduction  of 
the  needle. 


Extraction.      The    methods  of  extraction 
may  be  classified  as — 
The  flap ; 
Von  Graefe's ; 
The  linear ; 
The  scoop ; 

Extraction  by  suction  ;  and 
Removal  of  the  lens  in  its  capsule. 

Flap  Extraction.  The  common  flap  ope- 
ration is  certainly  the  best  when  it  is  success- 
ful. It  is  nearly  painless,  does  not  affect  the 
appearance  of  the  eye,  and  leaves  a  natural 

Fig.  173. 


Sichel's  knife. 


movable  pupil.  These  advantages,  however, 
are  offset  by  serious  disadvantages  ;  the  great 
size  of  the  flap  involves  the  risk  of  partial  or 
diffuse  suppuration  of  the  cornea,  accom- 
panied possibly  by  suppurative  iritis  or  irido- 
choroiditis.  Prolapse  of  the  iris  is  a  not  in- 
frequent complication,  and  the  after-treatment 
requires  much  more  care  and  attention.  But 
at  present  this  operation  is  performed  about 
as  often  as  von  Graefe's,  and  with  the  latter's 
knife  instead  of  Beer's. 

The  instruments  required  are  a  Beer's  (Fig. 
158)  or  Sichel's  (Fig.  173)  or  von  Graefe's 
(Fig.  177)  knife,  fixation  forceps,   Graefe's 
cystotome  and  curette  (Fig.  174),  and  a  small  blunt-pointed 
knife  or  pair  of  scissors  for  enlarging  the  wound,  if  necessary. 


Von  Graefe's 
cystotome  and 
curette. 


322 


OPERATIVE  SURGERY. 


The  section  may  be  made  iu  the  upper  or  lower  half  of 
the  cornea  ;  the  former  is  rather  the  more  advantageous,  the 
latter  the  easier  of  execution. 

Operation.  (Right  eye,  upper  section.)  First  Stage. 
Patient  recumbent,  the  operator  seated  behind  him.  The 
eyelids  are  separated  by  an  assistant  standing  at  the  patient's 
left  side,  and  drawing  the  lids  gently  apart  with  the  fore- 
finger of  each  hand,  without  making  any  pressure  upon  the 
eye.  The  surgeon  steadies  the  eyeball  by  pinching  up  a 
fold  of  conjunctiva,  with  fixation  forceps,  either  just  below 
the  cornea,  as  in  Fig.  175,  or  better,  perhaps,  just  below 
its  prolonged  horizontal  diameter  on  the  inner  side,  and 


Fig   175. 


Flap  extraction  of  cataract.    Mode  of  fixing  the  eye  and  making  the  incision. 

draws  the  eyeball  gently  down.  He  then  enters  the  point 
of  the  knife  at  the  outer  side  of  the  cornea  half  a  milli- 
metre within  its  margin,  and  just  on  its  transverse  diam- 
eter, and  carries  it  steadily  across  the  anterior  chamber, 
taking  care  to  keep  the  side  of  the  blade  parallel  to  the 
iris,  and  to  press  slightly  downward  with  its  back  so  that 
it  may  always  fill  the  incision  completely  and  prevent  the 
escape  of  the  aqueous  humor.  The  counterpuncture  is 
made  by  the  steady  advance  of  the  knife  at  a  point  imme- 
diately opposite  that  of  entry,  the  fixation  forceps  removed, 
and   the  knife  pushed  on  in  the  same  direction   until  the 


SPECIAL  OPERATIONS. 


323 


section  is  all  but  finished ;  when  only  a  small  bridge  of 
cornea  remains  undivided  at  its  upper  border,  the  edge  of 
the  knife  is  inclined  slightly  forward,  and  the  section  com- 
pleted by  withdrawing  the  knife.  Close  the  eyelids  for  a 
moment  before  beginning  the  second  stage. 

Second  Stage.  The  anterior  capsule  is  next  divided  by 
introducing  the  cystotome  through  the  incision  while  the 
patient  looks  downward,  and  drawing  its  point  gently 
across  that  membrane.  Care  must  be  taken  not  to  displace 
the  lens  by  pressing  the  point  too  forcibly  against  it.  Close 
the  eyelids  again  for  a  moment. 

Third  Stage.  The  patient  is  again  directed  to  look  down- 
ward, and  steady  gentle  pressure  is  made  upon  the  eye  with 
the  forefinger  or  curette  placed  upon  the  lower  lid  (Fig. 
176).     This  pressure  should  first  be  directed  backward  so 

Fig.  176. 


Flap  extraction  of  cataract.    Removal  of  the  lens  by  pressure. 


as  to  tip  the  upper  edge  of  the  lens  forward,  and  then  up- 
ward and  backward  so  as  to  force  the  lens  through  the 
dilated  pupil  into  the  anterior  chamber  and  out  through  the 
incision.  It  should  be  gentle  and  very  steady  so  as  to  avoid 
rupture  of  the  posterior  capsule  and  escape  of  the  vitreous 
humor. 

Any  portions  of  the  cortical  substance  of  the  lens  which 
may  have  been  left  behind  in  the  capsule,  or  stripped  off 


324 


OPERATIVE  SURGERY. 


Fig.  177. 


Von  Gracfe's 
cataract  knife. 


during  the  passage  of  the  lens 
through  the  pupil  and  the  incision, 
must  then  be  removed,  and  the  eye 
closed. 

Such  was  the  operation  employed 
for  extraction  of  the  ordinary,  hard, 
senile  cataract.  The  objections  to 
it,  as  before  mentioned,  were  the 
great  size  of  the  flap,  the  possible 
prolapse  of  the  iris  during  the 
after-treatment,  and  the  risk  of  iritis 
fig.  i7s.  excited  by  the  bruising  of  the  iris 
during  the  passage  of  the  lens 
through  the  pupil.  Von  Graefe 
was  the  first  to  suggest  that  this 
last  risk  would  be  diminished  by 
the  excision  of  a  portion  of  the 
iris,  iridectomy,  and  on  putting 
the  suggestion  into  practice  he 
found  that  it  also  enabled  him  to 
remove  the  cataract  safely  through 
a  much  smaller  incision.  Accord- 
ing to  Mr.  Carter,1  Von  Graefe 
worked  very  sedulously  during  sev- 
eral years  at  the  endeavor  to  ex- 
clude, one  by  one,  the  chief  sources 
of  the  dangers  by  which  extraction 
was  beset,  and  he  arrived  at  last  at 
the  point  of  losing  only  four  eyes 
out  of  one  hundred  operations.  A 
few  improvements  in  detail  have 
been  added  since  his  death,  but  so 
far  as  principles  and  broad  outlines 
are  concerned  he  had  covered  the 
ground.  In  view  of  the  shortness 
of  the  incision,  which  occupies  not 
more  than  one-quarter  of  the  periph- 
ery of  the  cornea,  the  operation  is 
generally  spoken  of  as  a  "  modified 
linear  extraction  ;"  but  the  curved 


'  Holmes's  Surgery,  its  Principles  and  Practice,  p.  724. 


SPECIAL  OPERATIONS.  325 

outline  of  the  incision,  and  the  fact  that  the  lens  is  removed 
entire,  certainly  bring  it  within  the  class  of  flap  extrac- 
tions. 

Von  Graefe's  Method.  Modified  Linear,  or  Modified 
Flap  Extraction.  The  instruments  required,  besides  the 
eye-speculum  and  fixation  forceps,  are  a  long,  thin,  nar- 
row knife  (Fig.  177),  the  blade  of  which  is  thirty  milli- 
metres long  and  two  millimetres  wide,  iridectomy  forceps 
(Fig.  178),  scissors,  a  cystotome  (Fig.  174),  and  a  small 
hard-rubber  or  tortoise-shell  curette. 

The  patient  is  etherized  and  recumbent ;  the  surgeon 
stands  or  sits  behind  him,  holding  the  knife  in  his  right 
hand  for  the  right  eye,  in  the  left  hand  for  the  left  eye. 
The  eyeball  is  secured  with  the  fixation  forceps,  and  the 
point  of  the  knife  is  entered  in  the  sclerotic  with  its  edge 
upward,  one  millimetre  from  the  upper  and  outer  margin  of 
the  cornea,  and  two  millimetres  below  a  tangent  to  its  circle 
drawn  at  the  upper  end  of  its  vertical  diameter  (Fig.  179, 
A).  The  point  of  the  knife  is  at  first  directed  toward  the 
centre  of  the  eyeball,  but  as  soon  as  it  has  penetrated  to  the 

Fig.  179.  Fig.  180. 


Diagram  to  illustrate  the  method  of  Line  of  Von  Graefe's 

making  von  Graefe's  incision.  incision. 

anterior  chamber  it  is  turned  so  as  to  pass  parallel  to  and 
along  the  anterior  surface  of  the  iris  downward  and  inward 
about  seven  millimetres  to  a  point  corresponding  to  B  in 
Fig.  179.  The  handle  is  then  depressed,  turning  on  the 
back  of  the  blade  in  the  incision,  until  the  point  is  raised  to 
the  horizontal  line  of  the  puncture,  when  the  haudle  must 
be  inclined  somewhat  backward,  and  the  point  pushed 
sharply  through  the  sclerotic  and  conjunctiva  at  C,  Fig. 
179.  Great  care  must  be  taken  not  to  make  the  counter- 
puncture  too  far  back  in  the  sclerotic,  a  mistake  which  may. 

15 


326  OPERATIVE  SURGERY. 

easily  happen  if  the  blade  is  carried  too  far  downward  and 
inward  before  it  is  turned  up  to  make  the  counter-puncture. 

The  edge  is  then  directed  forward,  and  the  incision  com- 
pleted by  steady  advance  and  withdrawal  of  the  knife. 
The  incision  is  represented  by  the  upper,  undotted  line  in 
Fig.  180  ;  its  centre  should  lie  at  the  juncture  of  the  cornea 
and  sclerotic.  The  little  bridge  of  conjunctiva  which  re- 
mains at  the  centre  of  the  incision  is  then  divided  in  such 
manner  as  to  leave  a  conjunctival  flap  two  or  three  milli- 
metres long  adherent  by  its  base  to  the  cornea.  If  the  cata- 
ract is  large  and  hard,  it  may  be  advisable  to  use  a  broader 
knife,  and  make  the  points  of  puncture  and  counter-puncture 
one  millimetre  lower,  so  that  it  will  not  be  necessary  to  use 
a  sco^p  or  make  much  pressure  on  the  eye  to  effect  the 
removal  of  the  lens. 

Many  surgeons  prefer  to  make  the  incision  wholly  in  the 
cornea  and  close  to  its  edge,  on  the  ground  that  the  wound 
will  heal  more  promptly  and  kindly,  and  be  accompanied 
by  less  risk  of  loss  of  the  vitreous  or  of  prolapse  of  the 
iris. 

The  object  of  the  iridectomy,  which  is  the  next  step  in 
the   operation,  is  the  neutralization   of  the  circular  fibres 

Fig.  181. 


Diagram  of  the  correct  and  faulty  sections  of  the  iris. 

rather  than  the  removal  of  a  large  portion  of  the  iris, 
although  some  surgeons  counsel  the  latter  on  account  of 
the  greater  security  it  gives  against  subsequent  inflamma- 
tion. The  iridectomy  forceps  are  introduced  closed,  and 
opened  slightly  when  the  point  reaches  the  margin  of  the 
pupil.  The  margin  rises  between  the  branches,  is  seized, 
withdrawn  gently,  and  cut  off  with  scissors  close  to  the 
forceps.  If  tin's  is  properly  done  the  angles  formed  by  the 
edges  of  the  incision  and  the  margin  of  the  pupil  will 
appear  in  the  anterior  chamber  as  at  A  and  B  in  Fig.  181. 


SPECIAL  OPERATIONS.  327 

The  portion  of  iris  removed  should  extend  quite  to  its  cil- 
iary insertion  so  that  there  may  be  none  to  engage  in  the 
external  incision  and  prevent  its  primary  union. 

The  capsule  is  next  freely  divided  by  two  successive 
lacerations  made  with  the  cystotome.  Each  should  begin 
at  the  lower  edge  of  the  pupil  and  extend  upward,  one 
along  the  inner,  the  other  along  the  outer  side,  to  the  upper 
border  of  the  lens,  where  it  has  been  exposed  by  the  iri- 
dectomy. This  upper  border  should  also  be  torn  to  an 
extent  corresponding  to  the  external  incision.  This 
manoeuvre  must  be  executed  with  great  delicacy  and  light- 
ness of  touch,  in  order  that  the  lens  may  not  be  displaced 
into  the  vitreous  humor. 

The  escape  of  the  lens  is  aided  by  pressure  upon  the  cor- 
nea with  the  curette.  The  fixation  forceps  are  applied  at 
the  inner  or  outer  side,  and  the  curette  placed  upon  the 
lower  edge  of  the  cornea  and  pressed  slightly  backward 
and  upward  so  as  to  cause  the  upper  edge  of  the  lens  to 
present  in  the  section  ;  the  pressure  must  then  be  made 
directly  backward,  in  order  that  the  lens  may  be  rotated 
around  its  transverse  axis  and  tilted  well  forward  into  the 
incision.  The  curette  is  then  pushed  slowly  upward  over 
the  surface  of  the  cornea  so  as  to  follow  step  by  step  the 
delivery  of  the  lens.  Any  fragments  scraped  off  during 
the  passage  may  be  removed  by  passing  the  curette  again 
over  the  surface  of  the  cornea. 

If  the  vitreous  humor  happens  to  be  liquid  it  may  es- 
cape as  soon  as  the  first  incision  is  made.  In  such  a  case  it 
is  best  to  excise  a  portion  of  the  iris  and  remove  the  lens  in 
its  capsule  by  passing  a  scoop  behind  it  into  the  vitreous 
humor  and  lifting  it  out. 

Gayet  and  Knapp's  Modification.  Instead  of  lacerating 
the  capsule  as  above  described  these  surgeons  incise  it  with 
a  knife-needle  along  the  line  of  the  corneal  incision.  This 
is  followed  in  the  great  majority  of  cases  by  an  unusually 
uneventful  healing  free  from  iritis  and  other  complica- 
tions, but  leaves  the  pupillary  area  occupied  by  the  cap- 
sule of  the  lens.  In  order  to  clear  the  pupil  the  capsule 
is  subsequently  (in  the  third  week  after  the  extraction, 
or  later)  split  with  the  knife-needle,  which   permanently 


328 


OPERA TIVE  S VRGEB  Y. 


frees  the  pupil  from  both  the  anterior  and  posterior  cap- 
sules. 

Linear  Extraction.  Mr.  Dixon  suggests1  rectilinear  ex- 
traction as  a  more  suitable  name,  because  the  incision  in 
the  cornea  is  a  straight  one,  in  contradistinction  to  that  of 
a  flap  extraction  which  also  forms  a  line,  but  a  curved 
one.  This  operation  is  a  modification  of  one  invented 
by  Gibson  in  1811,  which  had  fallen  into  entire  disuse  be- 
fore its  reintroduction  by  Von  Graefe  in  1855.  It  is  de- 
signed for  the  removal  of  soft  cataracts  through  a  small 
corneal  incision,  especially  the  cortical  cataract  of  individ- 
uals between  ten  and  thirty  years  of  age.  It  is  also  often 
employed  with  advantage  as  supplementary  to  the  needle 
operation.     It  is  performed  as  follows  : 

A  straight,  vertical  incision,  from  four  to  six  milli- 
metres long,  is  made  on  the  outer  side  of  the  cornea,  about 
two  millimetres  within  its  margin,  with  a  straight  lance- 
shaped  iridectomy  knife,  which  is  passed  into  the  anterior 
chamber  parallel  to  the  surface  of  the  iris.  The  capsule  is 
then  freely  lacerated  with  the  cystotome,  and  the  escape  of 
the  soft  lens  facilitated  by  the  introduction  of  a  curette  into 
the  wound,  and  by  making  gentle  pressure  on  the  inuer 
side  of  the  eye  with  the  finger.     If  portions  of  the  cortex 


Fig.  182. 


Fig.  188. 


\ 


Critchett's  scoops. 


Bowman's  scoops. 


remain  behind  the  iris  they  cau  be  brought  into  the  ante- 
rior chamber  by  closing  the  lids  and  making  gentle  pressure 
in  circular  liues  upon  them.  If  the  iris  protrudes,  it  must 
be  gently  replaced,  or,  if  much  bruised,  excised. 

Scoop  Extraction.     This  is  a  modification  of  linear  ex- 
traction, devised  by  Waldau  to  obviate  the  dangers  and  dif- 


Holines'e  System  of  Surgery,  vol,  lii,  p.  199. 


SPECIAL  OPERATIONS. 


329 


ficulties  occasioned  by  the  pres- 
ence in  the  lens  of  a  hard 
nucleus  of  greater  or  less  size. 
As  the  principal  danger  lies 
in  the  bruising  of  the  iris,  Von 
Graefe  met  it  by  iridectomy, 
which  afterward  suggested  to 
Waldau  the  idea  of  introducing 
a  scoop  and  removing  the  lens 
without  making  any  pressure 
upon  the  eyeball. 

The  instruments  required  are 
a  bent  lance-shaped  iridectomy 
knife  (Fig.  160),  iridectomy 
forceps  and  scissors,  and  a  thin, 
flat,  slightly  concave  scoop. 
Waldau's  scoop  resembled  a 
small  spoon.  Three  different 
kinds  are  shown  in  Figs.  182, 
183,  184. 

The  eye-speculum  aud  fixa- 
tion forceps  having  been  ap- 
plied, an  incision,  eight  or  nine 
millimetres  long,  is  made  at  the 
upper  border  of  the  cornea 
where  it  joins  the  sclerotic. 
The  corresponding  portion  of 
the  iris  is  removed,  and  the 
capsule  freely  torn  with  the 
cystotome,  as  before  described. 

The  scoop,  with  its  convex- 
ity backward,  is  then  intro- 
duced and  carried  carefully 
down  behind  the  lens,  until 
its  extremity  has  passed  the 
lower  margin  of  the  latter,  and 
engaged  it  in  its  hook-like  end. 
It  is  then  withdrawn,  care 
being  taken  not  to  press  the 
lens  against  the  iris  and  cor- 
nea. If  a  little  of  the  vitreous 
humor  escapes  at  the  same 
time,  it  must    be    snipped  off 


Fig.  185. 


Curette  and  mouthpiece  for  removal 
of  cataract  by  suction. 


330  OPERATIVE  SURGERY. 

and  a  compress  applied.  It  is  better  to  remove  any  frag- 
ments of  the  lens  that  may  be  left  behind  by  gently  rub- 
bing the  eyeball,  rather  than  reintroducing  the  scoop. 

Removal  by  Suction.  Laugier  suggested,  in  1847,  the 
removal  of  soft  cataracts  by  aspiration  through  a  hollow 
needle.  Blanchot  modified  the  method  by  substituting  a 
small  cauula  for  the  needle,  and  introducing  it  through  au 
incision  in  the  cornea,  but  the  operation  was  not  favorably 
received  until  after  it  had  been  again  modified  by  T. 
Pridgin  Teale,  Jr ,  in  186-3,  who  recommended  it  as  a  sub- 
stitute for  pressure  in  the  removal  of  the  harder  portions 
of  the  cataract  by  linear  extraction,  and  as  supplementary 
to  discission.  The  instruments  required  are  a  broad  needle 
and  a  suction  curette.  The  latter  (Fig.  185)  is  described  by 
Mr.  Teale1  as  consisting  of  three  parts,  a  curette,  handle, 
and  suction  tube.  "  The  curette  is  of  the  size  of  the  ordi- 
nary curette,  but  differs  from  it  in  beiug  roofed  in  to  within 
one  line  of  its  extremity,  thus  formiug  a  tube  flattened 
ou  its  upper  surface,  and  terminating,  as  it  were,  in  a 
small  cup. 

The  anterior  capsule  is  first  ruptured  with  a  fine  needle 
passed  through  the  cornea,  and  then  an  opening  is  made 
with  a  broad  needle  iu  the  coruea  through  which  the  curette 
is  passed  to  the  centre  of  the  pupil.  The  soft  matter  is 
then  withdrawn  by  suction. 

Soelberg  Wells2  says  this  operation  has  been  employed  at 
the  Royal  London  Ophthalmic  Hospital  with  great  success, 
and  that  it  is  especially  indicated  in  cases  of  soft  cortical 
cataract.  If  the  cataract  is  somewhat  harder,  it  is  well  to 
break  it  up  with  the  needle  a  few  days  before  attempting  to 
remove  it. 

Removal  of  the  Lens  in  its  Capsule.  This  operation  is 
indicated  when  the  capsule  is  opaque,  and  whenever  the 
eye  is  exceptionally  irritable,  or  has  been  chronically  in- 
flamed, so  that  the  accidental  retention  of  any  fragments  of 
the  lens  would  be  a  source  of  serious  danger.     When  suc- 

1  Ophthalmic  Hospital  Reports,  vol.  iv.  part  2,  p.  197. 

-  On  the  Diseases  of  the  Eye,  p.  280.    Philadelphia :  U.  C.  Lea. 


SPECIAL  OPERATIONS.  331 

cessful,  this  method  gives  very  fine  results,  but  its  risks 
and  dangers  are  so  great  that  it  is  seldom  employed.  Orig- 
inally iutroduced  by  Richter  and  Beer,  it  was  revived  by 
Sperino,  Pagenstecher,  and  Wecker.  The  former  employed 
the  ordinary  flap  operation  without  laceration  of  the  cap- 
sule. Pagenstecher  made  a  large  flap  in  the  sclerotic 
together  with  iridectomy.  Wecker's  method  was  nearly 
identical,  the  incision  being  made  at  the  sclero-corneal  junc- 
tion. 

Pagenstecher' s  Method.  The  patient  having  been  thor- 
oughly anesthetized,  a  large  flap  is  made,  usually  down- 
ward, with  a  Beer's  knife,  a  small  bridge  of  conjunctiva 
being  left  temporarily  at  its  apex.  Iridectomy  is  then  per- 
formed in  the  outer  lower  quadrant,  and  the  conjunctival 
bridge  divided  with  blunt-pointed  scissors.  Any  posterior 
synechias  that  may  exist  are  torn  through  with  a  fine  silver 
hook,  and  then  the  lens  removed  in  its  capsule  by  slight 
pressure  upon  the  eyeball.  If  the  hyaloid  membrane  should 
be  ruptured  and  the  vitreous  escape,  the  lens  must  be  re- 
moved with  the  aid  of  a  small  scoop  passed  in  behind  its 
lower  edge. 

Secondary  Cataract.  Secondary  cataracts  vary  much  in 
thickness  and  opacity.  They  may  be  produced  by  portions 
of  the  lens  left  behind  and  becoming  entangled  in  the  cap- 
sule, by  the  deposit  of  lymph  upon  the  latter,  or  by  the 
proliferation  of  the  intracapsular  cells.  No  operation  for 
secondary  cataract  should  be  performed,  until,  at  least, 
three  or  four  months  after  the  removal  of  the  primary  cata- 
ract; and  if  the  pupil  has  become  contracted,  or  if  very 
extensive  posterior  synechias  have  formed,  a  preliminary 
iridectomy  should  be  made.  Formerly  the  plan  was  to 
remove  the  opaque  and  thickened  membrane  entirely  from 
the  eye,  but  it  has  proved  very  much  safer  and  equally 
efficacious  to  make  a  small  opening  in  the  membrane  with 
a  needle. 

Cocaine  anaesthesia  is  necessary.  The  eye-speculum  and 
fixation  forceps  having  been  applied,  Bowman's  fine  needle 
(Fig.  171)  is  passed  through  the  cornea  near  its  margin,  and 
an  effort  made  to  tear  a  hole  with  it  in  the  centre  of  the 
membrane  or  at  the  part  which  is  thinnest  and  least  opaque. 


332  OPERATIVE  SURGERY. 

If  the  membrane  yields  before  the  needle,  or  if  it  is  too 
tough  to  be  torn,  Mr.  Bowman's  device  of  a  second  needle 
must  be  employed.  This  is  to  be  passed  through  the  cornea 
on  the  side  opposite  to  that  occupied  by  the  first  needle, 
and  then  the  operator,  transfixing  and  steadying  the  mem- 
brane with  one  needle,  tears  it  with  the  other.  If  any  por- 
tion of  the  iris  should  happen  to  be  bruised  or  torn,  it  must 
be  excised  through  a  linear  excision. 

Dr.  Agnew  passes  a  needle  through  the  centre  of  the 
membrane,  thus  steadying  both  it  and  the  eye.  He  then 
makes  a  linear  incision  on  the  temporal  side  of  the  cornea 
through  which  he  passes  a  small  sharp-pointed  hook,  the 
point  of  which  is  passed  into  the  same  opening  in  the  mem- 
brane as  the  needle.  He  next  tears  the  membrane,  rolls  it 
up  about  the  hook,  and  either  draws  it  out  altogether,  or,  if 
this  cannot  be  done,  tears  it  widely  open. 


OPERATION   TO    CORRECT   STRABISMUS — STRABOTOMY. 

The  tendon  of  the  internal  rectus  is  attached  to  the 
sclerotic  at  a  distance  of  five  millimetres  from  the  border 
of  the  cornea,  that  of  the  external  rectus  at  a  distance  of 
seven  millimetres.  Each  tendon  is  seven  or  eight  milli- 
metres broad  and  is  contained  in  a  firm  sheath  resembling 
a  glove  finger,  a  prolongation  or  depression  of  the  capsule 
of  Tenon  at  the  point  where  it  is  traversed  by  the  tendon 
about  midway  between  the  anterior  margin  of  the  orbit  and 
the  posterior  pole  of  the  eyeball.  The  capsule  of  Tenon  is 
a  reflection  of  the  periosteum  of  the  orbit  from  the  anterior 
margin  of  the  latter  to  the  transverse  meridian  of  the  eye- 
ball and  thence  backward  to  and  along  the  optic  nerve,  thus 
constituting  a  diaphragm  which  divides  the  orbit  into  an 
anterior  and  a  posterior  loge,  the  former  of  which  contains 
the  eyeball  (received  into  a  cup-like  depression  of  the  dia- 
phragm), the  latter  the  muscles  and  optic  nerve.  The  cap- 
sule sends  a  prolongation,  not  only  anteriorly  along  the 
tendons,  but  also  posteriorly  along  the  muscles,  and  the 
union  between  the  muscle  and  sheath  is  so  firm  that  even 
after  division  of  the  tendon  the  muscle  can  move  the  eye- 
ball by  acting  through  the  attachments  of  the  capsule.     If 


SPECIAL  OPERATIONS. 


333 


the  body  of  the  muscle  itself  is  divided  in  the  posterior 
loge,  its  influence  upon  the  movements  of  the  eyeball  is 
entirely  lost.  This  is  the  chief  point  to  be  borne  in  mind 
in  performing  strabotomy,  the  tendon  must  be  divided,  not 
the  muscle,  and  the  amount  of  deviation  of  the  eye  to  be 
overcome  is  the  measure  of  the  extent  to  which  the  adjoin- 
ing tissues  must  be  divided. 

The  Operation  for  Division  of  the  Internal  Rectus  will 
alone  be  described,  that  being  the  one  commonly  required. 
The  special  instruments  required  are  :  fine-toothed  forceps 
(Fig.  186),  blunt  hook  (Fig.  187),  and  blunt-pointed  scis- 
sors, straight  or  curved  on  the  flat. 

A  small  but  deep  fold  of  conjunctiva  and  subconjunctival 
tissue  is  seized  with  the  toothed  forceps  just  above  the 
lower  extremity  of  the  line  of  insertion  of  tendon  of  the 

Fig.  186. 


Fig.  187. 


internal  rectus,  that  is,  two  millimetres  below  a  point  on 
the  equator  of  the  eyeball  five  millimetres  beyond  the  inner 
margin  of  the  cornea,  and  divided  with  the  scissors  just 
below  the  forceps  ;  additional  snips  are  made  with  the  scis- 
sors within  this  opening  until  the  tendon  or  the  sclerotic  is 
exposed.  The  surgeon  then  passes  the  point  of  the  stra- 
botomy hook,  which  should  be  somewhat  bulbous,  through 
the  opening  to  the  lower  border  of  the  tendon,  and,  keep- 
ing the  point  and  side  of  the  hook  constantly  upon  the 
sclerotic,  sweeps  it  at  first  backward,  and  then  upward  and 
forward  around  the  insertion.  When  this  manoeuvre  is  prop- 
erly executed,  the  point  of  the  hook  can  be  seen  under  the 
conjunctiva  above  the  upper  border  of  the  tendon,  while  its 

15* 


334 


OPERATIVE  SURGERY. 


course  is  hidden  by  the  latter  and  prevented  from  being 
drawn  forward  to  the  margin  of  the  cornea.  If  the  whole 
of  the  hook  can  be  seen  under  the  conjunctiva,  it  is  not 
under  the  tendon,  and  the  sweep  must  be  repeated.  When 
the  tendon  has  been  secured,  the  conjunctiva  may  be  pressed 
back  over  its  point,  and  the  tendon  divided  with  scissors 
close  to  its  insertion,  beginning  at  its  upper  border  ;  or,  the 
conjunctiva  being  left  in  place,  the  scissors  may  be  passed 
along  the  hook  as  a  guide,  one  blade  below  the  tendon,  the 
other  between  it  and  the  conjunctiva,  and  the  tendou  divided 
with  repeated  snips. 

After  the  tendon  has  been  completely  cut  through,  the 
hook  should  be  swept  upward  and  downward  to  ascertain 
if  the  lateral  expansions  of  the  tendon  have  been  divided, 
for  the  persistence  of  even  a  few  of  them  might  be  sufficient 
to  prevent  the  success  of  the  operation. 

If  it  is  feared  that  too  great  an  effect  has  been  produced, 
a  deep  suture  may  be  passed  through  the  tendon  and  the 
conjunctiva  on  the  side  toward  the  cornea  so  as  to  limit  the 


Fro.  188. 


Fig.  189. 
B' 


Method  of  estimating  the  degree 
of  squint. 


Double  operation  for  strabismus. 


amount  of  retraction.  The  accommodative  movements  of 
the  eye  should  be  tested  immediately  after  the  operation, 
and  if  there  is  the  slightest  tendency  to  divergence  when 
the  object  is  six  or  eight  inches  distant  from  the  eye  a  suture 
should  be  inserted. 

In  the  subconjunctival  method  the  incision  in  the  conjunc- 


SPECIAL  OPERATIONS.  335 

tiva  is  made  below  the  insertion  of  the  tendon  on  a  line 
with  the  lower  border  of  the  cornea,  and  the  conjunctiva  is 
not  pressed  away  from  the  anterior  surface  of  the  tendon 
after  the  hook  has  been  passed  under  the  latter. 

If  the  squint  exceeds  five  or  six  millimetres,  as  estimated 
by  the  method  shown  in  Fig.  188,  both  eyes  should  be  ope- 
rated upon,  but  at  separate  times,  the  insertion  of  the  in- 
ternal rectus  being  set  back  in  each  case.  Thus,  if  the  de- 
gree of  squint  represented  in  Fig.  189  were  corrected  by 
setting  back  the  tendon  of  the  internal  rectus  from  O  to  D, 
the  muscle  could  only  work  at  a  great  disadvantage  as  com- 
pared with  the  internal  rectus  of  the  other  side,  and  the 
result  would  be  the  appearance  of  divergent  squint  when- 
ever the  attempt  was  made  to  look  at  an  object  near  the 
eye,  because  the  muscle  could  not  turn  the  eye  far  enough 
inward.  The  condition  must  therefore  be  divided  between 
the  two  eyes,  the  internal  rectus  on  one  side  being  set  back 
to  E,  on  the  other  side  to  Er. 

Secondary  Strabismus  following  Tenotomy  of  the  oppo- 
nent is  treated  by  advancing  the  insertion  of  the  tendon  of 
the  latter  (Prorraphy).  Thus,  supposing  divergent  squint 
to  have  followed  division  of  the  internal  rectus,  an  incision 
half  an  inch  long  is  made  in  the  conjunctiva  in  the  line  of 
the  horizontal  diameter  of  the  cornea,  and  the  conjunctiva 
and  subconjunctival  tissue  dissected  up  as  far  back  as  to 
the  caruncle.  A  hook  is  then  passed  around  the  insertion 
of  the  internal  rectus,  and  the  tendon  divided  as  before; 
a  suture  is  passed  through  it,  and  it  is  drawn  toward,  and 
fastened  to,  the  strip  of  conjunctiva  adjoining  the  inner 
border  of  the  cornea.  The  tendon  of  the  external  rectus 
must  then  be  divided  according  to  the  rules  laid  down  for 
division  of  the  internal  rectus,  remembering  that  its  attach- 
ment to  the  sclerotic  is  distant  seven  millimetres  from  the 
edge  of  the  cornea. 


ENUCLEATION  OF  THE  EYEBALL. 

As  the  globe  of  the  eye  lies  somewhat  nearer  the  inner 
than  the  outer  side  of  the  orbit,  it  will  be  found  easier  to 


336  OPERATIVE  SURGERY. 

approach  it  from  the  latter  quarter.  Tillaux1  divides  the 
conjunctiva  and  subconjunctival  fascia  with  curved  scissors 
along  the  attachment  of  the  external  rectus,  divides  the 
tendon  of  that  muscle,  carries  the  scissors  backward  through 
the  incision,  their  concavity  turned  toward  the  globe,  and 
cuts  the  optic  nerve  close  to  the  eyeball.  He  then  seizes 
the  posterior  pole  of  the  globe  with  pronged  forceps,  draws 
it  out  through  the  conjunctival  incision,  and  divides  the 
remaining  conjunctival  attachments  and  tendons  close  to 
the  sclerotic. 

Other  surgeons  prefer  to  seek  and  divide  each  tendon  in 
turn  before  cutting  the  optic  nerve. 

Extirpation  of  the  Entire  Contents  of  the  Orbit.  In  order 
to  gain  additional  room,  it  is  well  first  to  divide  the  external 
commissure  of  the  lids.  A  bistoury  is  then  entered  at  the 
inner  angle,  carried  well  back  toward  the  apex  of  the  orbit, 
and  swept  along  the  floor  to  the  outer  angle,  then  reintro- 
duced at  the  inner  angle,  and  carried  along  the  roof  of  the 
orbit  to  the  outer  angle.  The  muscles  and  optic  nerve, 
which  still  remain  attached  to  the  eye  and  apex  of  the  orbit, 
are  finally  divided  with  curved  scissors  introduced  from  the 
outer  side. 

Hemorrhage  should  be  arrested  by  packing  the  cavity 
with  antiseptic  gauze. 


OPERATIONS  UPON  THE  LACHRYMAL  APPARATUS. 

Extirpation  of  the  Lachrymal  Gland  (Fig.  190).  The 
principal  portion  of  the  lachrymal  gland  lies  just  behind  the 
junction  of  the  upper  and  outer  margins  of  the  orbit,  envel- 
oped in  a  fibrous  capsule  formed  by  a  reflection  of  the  peri- 
osteum or  capsule  of  Tenon.  The  "  accessory  "  portion,  to- 
gether with  the  ducts,  occupies  the  adjoining  eyelid,  and  is 
composed  of  isolated  granulations  of  granular  tissue,  which, 
if  left  behind  after  removal  of  the  main  portion,  may  con- 
tinue to  secrete  tears  and  discharge  them  into  the  wound, 
thus  causing  abscesses  and  fistulas. 

Tillaux2  has  pointed  out  that  the  existence  of  the  fibrous 

1  Anatomic  Topographique,  p.  190. 

2  Anatomic  Topographique,  p.  237. 


SPECIAL  OPERATIONS.  337 

capsule  renders  it  possible  to  enucleate  the  gland  without 
opening  the  posterior  loge  of  the  orbit,  a  defect  in  the  older 
methods  which  included  division  of  the  external  commissure. 
Make  an  incision  one  inch  in  length  along  the  upper  and 
outer  portion  of  the  bony  margin  of  the  orbit.  Carry 
this  incision  through  all  the  soft  parts,  including  the  perios- 
teum, down  to  the  bone ;  separate  the  periosteum  from  the 
bone  at  the  under  side  of  the  incision,  and  depress  it.    The 

Fig.  190. 


Extirpation  of  the  lachrymal  gland.  S.  Skin.  P.  Periosteum.  B.  Frontal 
bone.  Q.  Lachrymal  gland.  T.  Capsule  of  Tenon.  R.  Reflected  periosteum 
forming  the  capsule  of  the  gland.  E.  Eyeball.  C.  Conjunctiva.  L.  Eyelid.  I. 
Incision. 

gland  can  then  be  distinctly  seen  through  the  thin  layer  of 
periosteum  which  separates  it  from  the  roof  of  the  orbit,  and 
can  be  removed  with  great  ease  after  the  latter  has  been  torn 
through. 

Lachrymal  Sac,  Duct,  and  Canaliculi.  The  lower  cana- 
liculus passes  downward  from  the  punctum  for  two  milli- 
metres, then  turns  at  a  right  angle,  and  passes  horizontally 
inward  to  the  lachrymal  sac,  a  distance  of  about  five  milli- 
metres ;  the  upper  canaliculus  passes  at  first  upward  for  two 
millimetres,  and  then  downward  and  inward  to  the  sac.  This 
sharp  turn  in  the  course  of  the  canaliculus,  which  is  an 
obstacle  to  catheterization,  can  be  temporarily  removed  by 
drawing  the  border  of  the  lid  outward.  The  lachrymal 
sac  lies  just  behind  the  tendo  oculi,  and  receives  the  cana-. 


338 


OPERATIVE  SURGERY. 


Fig.  192. 


Fig.  191. 


Sharp-pointed  Bowman's  probe- 
canaliculus  dl-  pointed  canalicu- 
rector.  lus  knife. 


liculi  by  a  common  duct  two 
or  three  millimetres  below  its 
upper  extremity,  their  relations 
thus  resembling  those  of  the 
ileum  and  csecurn,  a  resem- 
blance which  is  increased  by 
the  presence  of  a  valve  at  the 
opening  of  the  duct  into  the 
sac.  This  valve,  described  by 
Huschka,  is  thought  to  prevent 
the  reflux  of  the  contents  of 
the  sac  into  the  canaliculi. 
The  direction  of  the  sac  is 
downward  and  backward  at  an 
angle  of  45°  ;  it  occupies  the 
lachrymal  groove,  which  is 
bounded  anteriorly  by  a  ridge 
on  the  nasal  process  of  the 
superior  maxillary  bone  at  the 
inner  angle  of  the  orbit,  and  is 
crossed  by  the  tendo  oculi  just 
at  the  junction  of  its  upper  and 
middle  thirds.  The  nasal  duct 
is  the  direct  continuation  of 
the  sac  and  passes  downward, 
backward,  and  outward ;  the 
combined  length  of  the  duct 
and  sac  is  about  one  inch. 

It  may  become  necessary  to 
slit  up  the  ccmalieulus  in  order 
to  correct  a  malposition  of  the 
punctum,  or  to  facilitate  cathe- 
terization of  the  sac  and  nasal 
duct.  This  little  operation  is 
best  performed  as  follows  (right 
eye,  lower  lid) :  The  surgeon 
stands  behind  the  patient,  who 
is  recumbent,  and  introduces  a 
fine  grooved  director  (Fig.  191) 
vertically  through  the  punctum 
for   a  distance   of  two   milli- 


SPECIAL  OPERATIONS.  339 

metres.  Then  drawing  the  border  of  the  lid  outward  and 
somewhat  downward  with  the  forefinger  of  his  left  hand, 
he  passes  the  director  horizontally,  with  its  groove  upward, 
along  the  canaliculus  to  the  inner  side  of  the  sac.  Then, 
shifting  the  director  to  the  left  hand,  he  engages  a  sharp- 
pointed  knife  in  the  groove,  and  slits  up  the  canaliculus 
throughout  its  entire  length. 

Bowman's  probe-pointed  canaliculus  knife  (Fig.  192) 
may  be  substituted  for  the  director  and  knife.  It  should 
be  very  narrow,  and  its  probe  point  very  small. 

When  one  puuctum  has  been  entirely  obliterated,  a  plan 
suggested  by  Mr.  Streatfeild  may  be  employed.  He 
divides  the  other  canaliculus,  passes  a  line  director,  suit- 
ably bent,  through  the  wound  into  the  obliterated  canali- 
culus and  cuts  down  upon  it. 

If  the  divided  lower  canaliculus  remains  everted,  Mr. 
Critchett  advises  that  the  posterior  lip  of  the  incision  be 
cut  off  with  scissors,  "effecting  the  treble  object  of  drawing 
the  canal  further  inward,  of  forming  a  reservoir  into  which 
the  tears  may  run,  and  of  preventing  reunion  of  the  parts." 

Puncture  of  the  Sac  (Fig.  193).  The  three  guides  are 
the  tendo  oculi,  the  anterior  margin  of  the  lachrymal  groove, 

Fig.  193. 


Puncture  of  the  lachrymal  sac. 


and  the  direction  of  the  sac.  While  an  assistant  draws  the 
external  commissure  outward,  so  as  to  make  the  tendo  oculi 
tense  and  plainly  visible,  the  surgeon  places  his  left  fore- 


340  OPERATIVE  SUBGEBY. 

finger  upon  the  inner  and  lower  margin  of  the  orbit,  so  as  to 
have  the  bony  edge  between  the  nail  aud  the  pulp  of  the 
finger,  and  holding  the  knife  in  the  direction  of  the  canal, 
that  is,  nearly  parallel  to  the  median  plane,  aud  at  an  angle 
of  45°  with  the  horizon,  he  passes  it  along  his  finger-nail 
into  the  sac  just  below  the  tendon.  It  is  important  to  mark 
the  position  of  the  anterior  margin  of  the  canal,  so  as  to 
avoid  the  not  infrequent  mistake  of  passing  the  knife  en- 
tirely outside  of  the  orbit  between  the  soft  parts  of  the  face 
and  the  bone. 

Stricture  of  the  Nasal  Duct.  Division.  Dr.  Stilling, 
of  Cassel,  proposes  to  treat  stricture  of  the  nasal  duct  by 
internal  division.     He  divides  the  canaliculus  and  ascer- 

FlG.  194. 


Stilling's  knife. 

tains  the  seat  of  the  stricture  with  a  probe,  passes  his  knife 
(Fig.  194)  through  it,  and  divides  it  in  three  or  four  direc- 
tions. 


CHAPTER  II. 

OPERATIONS   UPON   THE   EAR   AND    ITS   APPENDAGES. 
OCCLUSION   OF   EXTERNAL   AUDITORY   CANAL. 

Congenital  occlusion  of  the  external  meatus  is  usually 
associated  with  absence  or  defective  development  of  the 
other  portions  of  the  auditory  apparatus.  Before  operating 
upon  such  an  occlusion,  therefore,  the  hearing  power  should 
be  tested,  and  the  permeability  or  impermeability  of  the  bony 
portion  of  the  canal  determined  by  puncture  with  a  needle. 

If  the  occlusion  consists  of  a  simple  membranous  dia- 
phragm it  should  be  divided  crucially,  and  the  flaps  excised. 
For  deeper  and  more  extensive  obstructions  cauterization 
with  nitrate  of  silver  is  to  be  preferred. 


SPECIAL  OPERATIONS.  341 

INTRODUCTION   OF   SPECULUM   (ROOSA). 

The  upper  portion  of  the  auricle  is  grasped  between  the 
ring  and  middle  fingers  of  the  left  haud  and  drawn  gently- 
upward  and  backward.  Into  the  canal  thus  straightened 
the  speculum  is  introduced  with  the  right  hand,  and  then 
held  in  place  with  the  thumb  and  forefinger  of  the  left,  the 
hand  being  steadied  by  resting  its  ulnar  border  against  the 
patient's  head.  Complete  control  of  the  speculum  is  thus 
obtained,  and  it  can  be  easily  moved  about  so  as  to  bring 
every  part  of  the  tympanum  and  canal  into  view.  Light 
should  be  thrown  into  it  from  a  concave  mirror  perforated 
in  the  centre  and  having  a  focal  distance  of  six  inches. 


PARACENTESIS  OF  THE  MEMBRANA  TYMPANI  (ROOSA).1 

This  should  be  performed  while  the  head  of  the  patient 
is  well  supported  and  a  good  light  is  thrown  upon  the  mem- 
brane by  a  mirror  attached  to  a  forehead  band.  A  cataract 
needle  is  the  instrument  usually  employed,  and  the  opening 
should  be  made  in  the  posterior  inferior  quadrant  of  the 
membrane 

Tillaux2  calls  attention  to  the  fact  that  all  the  important 
elements  of  the  membrane  occupy  its  upper  half,  and  that 
an  incision  or  rupture  near  the  handle  of  the  hammer  may 
give  rise  to  troublesome  and  even  dangerous  hemorrhage. 
The  lower  half  is  less  vascular  and  less  sensitive. 

If  it  is  desired  to  maintaiu  the  opening  for  several  days, 
a  crucial  incision  maybe  made,  or  a  triangular  flap  excised, 
but,  as  a  rule,  even  these  incisions  heal  very  quickly. 


CATHETERIZATION    OF    THE    EUSTACHIAN    TUBE. 

The  Eustachian  tube  is  from  one  and  a  half  to  two  inches 
long,  its  course  is  from  the  pharynx  upward,  backward,  and 
outward.     Its  pharyngeal  orifice  is  oval  and  well  marked 

1  Treatise  on  the  Diseases  of  the  Ear,  p.  246. 
-  Anatomie  Topographique,  p.  111. 


342  OPERATIVE  SURGERY. 

except  on  the  lower  border,  and  is  situated  just  above  the 
base  of  the  soft  palate.  Behind  the  orifice,  between  it  and 
the  posterior  wall  of  the  pharynx,  is  a  depression  (Rosen- 
miiller's  fossette)  in  which  the  beak  of  the  catheter,  if  car- 
ried too  far  back,  may  lodge  and  give  the  same  sensation 
to  the  surgeon's  hand  as  if  it  were  enraged  in  the  tube. 
Of  the  two  mistakes  most  frequently  made  iu  performing 
catheterization,  one  is  to  pass  the  beak  of  the  instrument 
between  the  middle  and  inferior  turbinated  bones  instead  of 
along  the  floor  of  the  nasal  fossa,  and  the  other  is  to  mis- 
take Rosenmiiller's  fossette  for  the  orifice.  According  to 
Roosa,1  the  first  mistake  is  best  avoided  by  drawing  down 
the  patient's  upper  lip  with  the  left  hand,  and  entering  the 
catheter  while  it  is  held  in  an  almost  vertical  position,  its 
concavity  directed  toward  the  mediau  line.  After  the  beak 
has  fairly  entered  the  meatus  the  stem  of  the  catheter  is 
gradually  raised  to  the  horizontal  position  and  passed  back- 
ward, its  beak  resting  on  the  floor  of  the  meatus  close  to 
the  septum,  its  convexity  upward. 

Tillaux2  gives  the  following  directions  for  fiuding  the 
orifice:  1st.  Carry  the  catheter  directly  backward,  its  con- 
cavity downward,  until  it  touches  the  posterior  wall  of  the 
pharynx.  2d.  Withdraw  it  until  the  beak  rests  again  upon 
the  hard  palate.  3d.  Carry  the  catheter  again  very  gently 
backward,  and  feel  with  its  beak  for  the  posterior  border 
of  the  palatine  aponeurosis,  the  firm  fibrous  continuation  of 
the  palatal  bone.  This  aponeurosis  feels  as  hard  as  bone, 
and  its  posterior  border  can  be  easily  recognized  by  the 
softness  of  the  adjoining  tissues.  4th.  Rotate  the  beak  of 
the  catheter  outward  and  upward,  and  it  will  enter  the 
Eustachian  tube. 

OPENING    OF    THE    MASTOID    ANTRUM.'' 

The  incision  begins  just  above  the  apex  of  the  mastoid 
process  and  is  carried  upward  one  and  one-half  inches  paral- 
lel to  the  attachment  of  the  ear,  and  about  one-half  an  inch 
behind  it.  Everything  is  divided  down  to  the  bone,  the 
periosteum  elevated,  and  the  posterior  margin  of  the  meatus 

1  Diseases  Of  the  Kar,  p,  94.  -  Anatomic  Topogruphiquc,  p.  140. 

3  Birmingham  Dub.  Journ.  Med.  Sci.,  1891,  p.  116. 


SPECIAL  OPERATIONS.  343 

recognized.  A  one-quarter-inch  drill  or  gouge  is  driven 
straight  inward  at  such  a  point  that  the  hole  it  makes  shall 
lie  as  near  as  possible  to  the  back  of  the  bony  meatus  and 
its  upper  border  be  not  more  thau  one-twelfth  of  an  inch 
above  the  level  of  the  upper  margin  of  the  meatus.  It 
must  not  penetrate  deeper  than  three-quarters  of  an  inch 
or  the  external  semicircular  canal  will  be  damaged.  Deep 
perforations  back  of  a  line  one-quarter  of  an  inch  behind 
the  posterior  margin  of  the  meatus  are  liable  to  wound  the 
lateral  sinus.  The  antrum,  which  is  about  the  size  of  a 
pea,  is  usually  reached  at  a  depth  of  three-fifths  of  au  inch. 
The  opening  thus  made  into  it  may  afterward  be  enlarged 
and  any  necrosis  carefully  gouged  out,  and  the  wound  is 
finally  packed  and  drained. 

Stacke's  Method.1  An  incision  penetrating  to  the  bone 
throughout  is  made  parallel  to  aud  close  behind  the  attach- 
ment of  the  auricle  to  the  head,  starting  from  the  apex  of 
the  mastoid  process  aud  terminating  well  above  and  in 
front  of  the  ear  on  the  temporal  region.  The  soft  parts 
and  periosteum  are  elevated  toward  the  external  meatus 
and  the  bony  margin  of  the  latter  thus  exposed.  The  fun- 
nel of  skin,  periosteum,  and  cartilage  leading  into  the 
meatus  is  then  still  further  detached  with  a  fine  elevator 
and  cut  across  just  external  to  the  membrana  tympaui,  thus 
exposing  the  whole  of  the  bony  passage.  The  malleus, 
incus,  and  tympanum,  or  its  remains,  are  next  excised,  and 
the  outer  surface  of  the  mastoid,  together  with  the  posterior 
wall  of  the  external  meatus  and  middle  ear,  are  chiselled 
through,  making  a  gutter  extending  from  the  top  of  the 
tympanic  cavity  to  the  floor  of  the  aditus  ad  antrum.  The 
chorda  tympani  is  inevitably  divided,  but  the  facial  nerve 
and  the  labyrinth  are  avoided  by  carefully  keeping  ex- 
ternal to  the  inner  wall  of  the  tympanic  cavity.  After 
scraping  out  all  diseased  tissue  the  funnel  of  skin  and  peri- 
osteum, which  was  detached  from  the  external  meatus,  is 
split  in  its  long  axis  posteriorly  and  the  flaps  fitted  into 
the  bony  gutter,  thus  partially  providing  au  epidermic  cov- 
ering for  the  denuded  surfaces.  A  couple  of  sutures  in 
the  extremities  of  the  incision  aud  an  iodoform-gauze  pack- 
ing complete  the  operation. 

1  Berlin,  klin.  Wochensch.,  1892,  p.  68. 


344  OPERA TIVE  S UROER  Y 


CHAPTER    III. 

OPERATIONS    UPON    THE    MOUTH    AND    PHARYNX. 
EXCISION   OF   THE   TONSILS    (AMYGDALOTOMY). 

The  tonsils  may  be  excised  with  a  knife  and  volsella, 
or  with  a  specially  contrived  instrument,  the  tonsilotome 
or  guillotine. 

Anaesthesia  is  not  required.  If  the  patient  is  young  or 
nervous  it  is  well  to  put  a  large  piece  of  cork  between  the 

Fig.  195. 
^_^  ____^ jsszs^ B  /^» 

^^  G,  T/EMA  nn'&.co.    (T*~|j  A 

Tonsilotome. 

jaws  on  each  side  to  prevent  the  mouth  from  being  closed. 
The  tonsilotome  (Fig.  195)  is  composed  of  two  rings  and  a 
fork  mounted  upon  stems  so  arranged  that  they  can  be 
worked  with  the  thumb  and  fingers  of  one  hand.  The  two 
rings  slide  flatwise  upon  each  other,  and  the  inner  edge  of 
one  is  sharp,  so  that  when  drawn  across  the  other  it  divides 
anything  lying  within  it.  The  fork  is  thrust  forward 
across  the  ring  and  drawn  away  vertically  from  it  by  the 
same  movement  which  draws  one  ring  across  the  other. 
The  rings  having  been  placed  over  the  tonsil,  the  hook  is 
driven  into  the  latter  by  a  quick  movement  of  the  thumb 
and  finger  and  draws  it  further  into  the  ring,  holding  it 
tense  as  the  other  blade  cuts  across  its  base.  The  pain  is 
very  slight. 

If  the  tonsilotome  cannot  be  used  the  tonsil  must  be  seized 
with  pronged  forceps,  and  excised  between  them  and  the 
pillars  with  a  probe-pointed  knife,  the  posterior  portion  of 
the  blade  being  guarded  with  diachylon  plaster  so  as  to 
avoid  injury  to  the  tongue. 


SPECIAL  OPERATIONS.  345 


STAPHYLORAPHY. 


At  the  conclusion  of  his  historical  account  of  this  opera- 
tion Verneuil1  states  that  it  has  been  invented  four  different 
times.  The  earliest  record  of  the  operation  is  found  in  a 
French  book  published  in  1766,2  in  which  it  is  said  that  a 
dentist,  named  Lemonnier,  closed  a  fissure  of  both  hard  and 
soft  palates  by  freshening  its  edges  with  a  knife  and  bring- 
ing them  together  with  sutures.  He  also  closed  perforations 
of  the  hard  palate  by  exciting  suppuration  of  their  borders. 

In  1799  Eustache,  a  physician  of  Beziers,  proposed  to 
reunite  by  sutures  the  edges  of  an  incision  which  he  had 
made  the  day  before  in  the  soft  palate  of  a  patient  for  the 
purpose  of  removing  a  pharyngeal  polyp.  The  patient  re- 
fused the  operation.  Four  years  later,  in  1803,  Eustache 
sent  to  the  Academie  Royale  de  Chirurgie  at  Paris  a  re- 
markable paper  upon  congenital  fissures  in  the  soft  palate, 
and  asked  the  Society's  approval  of  the  operation  by  which 
he  proposed  to  close  them.  The  approval  was  withheld, 
and  there  is  no  record  of  any  further  steps  having  been 
taken. 

In  December,  1816,  Von  Graefe  said,  before  the  Medico- 
Chirurgical  Society  of  Berlin,  that,  after  many  unsuccessful 
attempts  to  close  fissures  of  the  soft  palate,  he  had  at  last 
succeeded  by  drawing  the  edges  together  with  sutures  after 
freshening  them  by  applying  muriatic  acid  and  the  tincture 
of  cantharides.  This  remark  was  reported  in  the  proceed- 
ings of  the  Society  in  Huf eland's  Journal,  January,  1817. 
Between  1816  and  1820  Von  Graefe  repeated  the  operation 
three  times,  each  time  without  success. 

In  1819,  Roux,  apparently  in  entire  ignorance  of  Von 
Graefe's  attempt,  closed  a  fissure  by  paring  the  edges  and 
applying  sutures.  The  case  at  once  became  very  widely 
known,  and  had  much  influence  in  popularizing  the  opera- 
tion. 

When  the  extent  of  the  lesion  which  staphyloraphy  is 
designed  to  repair  is  considered,  the  operation  seems  to  be 
very  simple.     It  is  only  necessary  to  freshen  the  edges  of 

1  Chirurgie  RGparatrice,  1877.    Art.  Staphylorrhaphie. 
-  Traite  des  Principalis  objets  de  Medecine,  par  Robert. 


346 


OPEEA  TIVE  S  UROER  Y. 


the  gap  and  draw  them  together  with  sutures.  Practically, 
however,  the  operation  is  a  difficult  one ;  the  parts  lie  at  a 
considerable  distance  from  the  surface,  the  manipulations 
are  constantly  interfered  with  by  involuntary  movements 
of  deglutition,  the  flow  of  blood  increases  the  obscurity, 
and  the  practical  difficulties  in  the  way  of  placing  the 
sutures  are  great.  Finally,  unless  some  of  the  muscles  of 
the  palate  are  divided,  the  tension  exerted  by  them  upon 
the  sutures  is  sufficient  to  prevent  union. 

A  great  variety  of  methods  have  been  suggested  to  over- 
come these  difficulties.  Mr.  T.  Smith  diminished  the  first 
by  the  invention  of  a  gag  (Fig.  196),  designed  to  hold  the 


Whitehead's  modification  of  Smith's  gag. 

jaws  apart  during  the  operation.  Prof.  Van  Buren  pre- 
vented the  passage  of  blood  into  the  trachea  during  the 
employment  of  anaesthesia  by  placing  the  patient  so  that 
the  head  should  hang  down  over  the  end  of  the  table,  and 
the  blood  escape  through  the  nose.  The  same  device  was 
afterward  employed  by  Trelat. 

Sir  William  Fergusson  relieved  the  tension  by  dividing 
the  levator  palati  on  each  side.  He  did  this  by  passing  a 
knife,  bent  at  a  right  angle,  through  the  cleft  and  dividing 


SPECIAL  OPERATIONS. 


347 


the  muscle  from  behind  forward,  without  touching  the 
mucous  membrane  on  the  anterior  face  of  the  palate.  The 
incision  should  be  perpendicular  to  the  centre  of  a  line 
joining  the  hamular  process  and  the  orifice  of  the  Eusta- 
chian tube.  The  former  can  be  readily  felt  just  behind  the 
last  upper  molar  tooth,  the  latter  can  usually  be  seen  through 
the  cleft  in  the  palate.  He  also  recommended  division  of 
the  palato-pharyngeus  muscle. 

Sedillot1  divided  the  muscle  from  before  backward.  He 
drew  the  velum  downward  and  inward  with  pronged  forceps, 
and  made  an  incision  downward  and  outward  about  one 
centimetre  above  and  on  the  outer  side  of  the  base  of  the 
uvula,  and  just  behind  and  on  the  inner  side  of  the  last 
upper  molar,  crossing  the  levator  palati  at  right  angles 
(Fig.  198).  A  length  of  one  centimetre  is  usually  suffi- 
cient, but  it  must  be  increased  if  the  muscular  contractions 
persist.  The  relaxation  of  the  parts  produced  by  these  in- 
cisions is  shown  by  a  comparison  of  Figs.  197  and  199. 
Unless  the  incisions  are  exceptionally  large  their  sides  re- 


FlG.  197 


Fig.  198. 


FIG.  199. 


main  in  contact ;  in  any  case  they  promptly  reunite.  He 
then  divided  the  anterior  and  posterior  pillars,  seizing  each 
in  turn  near  its  centre  with  pronged  forceps,  and  cutting  it 
with  scissors. 

Mr.  George  Pollock2  has  modified  this  slightly  by  making 

1  Medecine  Opfiratoire,  vol.  ii.  p.  65. 

2  Holmes's  System  of  Surgery,  vol.  iv.  p.  426. 


348 


OPERATIVE  SURGERY 


the  incision  on  the  anterior  surface  of  the  palate  smaller. 
One  of  the  halves  of  the  palate  is  drawn  toward  the  median 
line  by  means  of  a  ligature  passed  through  it  near  the  base 
of  the  uvula,  and  a  thin,  narrow  knife  is  entered  close  to 
the  hamular  process,  a  little  in  front  of  it  and  on  its  inner 
side,  and  its  point  carried  upward,  backward,  aud  some- 


FlG.  200. 


Division  of  muscles  of  soft  palate. 

what  inward,  until  it  can  be  seen  tli rough  the  cleft,  having 
divided  on  its  way  part,  if  not  all,  of  the  tendon  of  the 
tensor  palati.  The  blade  now  lies  above  most  of  the  fibres 
of  the  levator  (Fig.  200),  and  by  raising  the  handle  and 
cutting  downward,  as  the  knife  is  withdrawn,  an  incision  of 
considerable  length,  including  the  greater  portion  of  the 


SPECIAL  OPERATIONS.  349 

levator,  is  made  on  the  posterior  surface  of  the  palate,  while 
that  on  the  anterior  surface  need  not  be  greater  than  the 
breadth  of  the  knife.  If  the  muscle  has  been  effectually 
divided  the  palate  will  be  pendulous  and  flaccid,  and  will 
not  contract  spasmodically  when  pulled  upon.  If  any  re- 
sistance should  persist  the  knife  must  be  introduced  again 
through  the  wound  and  the  iucision  enlarged  downward. 

Roux  placed  his  sutures  by  putting  a  needle  at  each  end 
of  the  thread,  and  passing  them  from  behind  forward. 
Trelat  used  a  needle  fixed  upon  a  long  handle,  the  point 
bearing  the  eye  and  curved  in  the  form  of  a  U.  After 
having  been  threaded  the  point  of  the  needle  was  passed 
through  the  palate  from  behind  forward,  the  thread  was 
drawn  through  with  a  hook  or  forceps,  and  the  needle,  still 
threaded,  withdrawn  and  passed  in  the  same  manner  on  the 
opposite  side.  The  objection  to  these  and  to  all  other 
methods  in  which  the  needle  is  passed  from  behind  forward, 
is  that,  since  the  point  cannot  be  seen,  it  is  very  difficult  to 
make  the  punctures  on  one  side  correspond  properly  with 
those  on  the  other.  If  silk  sutures  are  used  each  end  may 
be  passed  from  before  backward,  the  two  tied  together 
loosely,  and  the  knot  pulled  back  through  one  of  the  punc- 
tures, thus  bringing  the  loop  behind  the  palate. 

The  method  now  usually  employed  is  the  one  introduced 
by  Berard.  A  curved  needle  fixed  on  a  long  handle  is 
threaded  with  a  ligature  three  feet  long,  and  its  point  passed 
through  the  palate  from  before  backward ;  the  thread  is 
caught  with  hook  or  forceps  on  the  posterior  side,  and  its 
end  drawn  out  through  the  mouth,  the  needle  is  then  with- 
drawn and  slipped  off  the  thread.  It  is  next  threaded  with 
a  second  ligature  and  passed  in  the  same  manner  through 
the  opposite  half  of  the  plate,  the  loop  seized  as  before, 
drawn  through  a  short  distance,  and  held  while  the  needle 
is  withdrawn,  leaving  the  thread  double  in  the  puncture — 
the  loop  behind  the  palate,  the  two  ends  in  front.  The  poste- 
rior end  of  the  first  ligature  is  then  passed  through  the  loop 
of  the  secoud  one  (Fig.  201,  6),  and,  by  the  withdrawal  of 
the  latter,  drawn  through  the  second  puncture  (Fig.  201,  a). 
Instead  of  using  the  same  needle  to  pass  both  ligatures,  it  is 
more  convenient  to  have  two  curved  spirally  in  the  opposite 
directions,  one  for  each  side. 

16 


350 


OPERATIVE  SURGERY. 


If  silver  sutures  are  used,  thread  loops  should  be  passed 
from  before  backward  on  each  side,  one  end  of  the  wire 
engaged  in  each  and  drawn  through. 

After  a  suture  has  been  passed,  the  ends  should  be  brought 
out  through  the  mouth,  and  tied  together  for  safety.  When 
all  have  been  passed,  the  anterior  one  is  drawn  upon  to 
bring  the  edges  of  the  cleft  together,  and  the  knot  tied. 


Fig.  201. 


Staphyloraphy  ;   passing  the  sutures. 


The  knot  may  be  an  ordinary  square  one,  an  assistant  hold- 
ing the  first  twist  with  dressing  forceps  until  the  second  is 
made,  or  it  may  be  a  noose,  as  shown  in  Fig.  201,  c,  secured 
by  a  second  knot.  If  silver  wire  is  used,  it  may  be  fast- 
ened by  twisting  it,  or  by  clamping  a  small  lead  button 
upon  it.  Verneuil  first  passes  the  ends  of  the  wire  through 
the  eyes  of  a  shirt  button,  and  then  ties  or  twists.  He 
thinks  this  favors  more  accurate  adjustment  of  the  edges, 
and  facilitates  removal  of  the  wire. 

The  edges  of  the  cleft  are  pared  by  seizing  the  tip  of  the 
uvula  with  toothed  forceps,  making  it  tense,  entering  the 
point  of  a  narrow-bladed  knife  one  or  two  millimetres  back 
from  the  edge,  and  cutting  down  to  the  tip;  then  turning 
the  knife  and  cutting  up  to  the  anterior  angle  of  the  cleft. 
Care  should  betaken  to  do  this  thoroughly.  When  the  cleft 
is  very  short  (bifid   uvula),  N6laton  employed  the  method 


SPECIAL  OPERATIONS.  351 

already  described  under  his  name  for  single  uncomplicated 
harelip.  The  flaps  were  left  adherent  to  each  other  at  the 
apex  (angle  of  the  cleft)  and  to  the  uvula  at  their  bases, 
turned  down,  and  the  raw  surfaces  drawn  together.  When 
the  cleft  was  too  long  for  this  he  separated  the  flaps  at  the 
apex,  shortened  them  by  trimming  off  the  free  ends,  turned 
them  down,  and  united  as  before. 

There  is  no  settled  rule  of  practice  establishing  the  order 
in  which  the  different  steps  of  the  operation  shall  be.  exe- 
cuted, except  that  most  surgeons  are  agreed  upon  the  ad- 
visability of  paring  the  edges  of  the  cleft  before  passing  the 
sutures.  Mr.  Callender  recommended  that  the  muscles 
should  be  divided  a  day  or  two  before  the  attempt  to  close 
the  cleft,  on  the  grouud  that  the  second  operation  is  much 
simplified  by  the  freedom  from  the  bleeding  occasioned  by 
division  of  the  muscles.  Mr.  Smith,  on  the  other  hand, 
stretched  the  palate  by  drawing  upon  all  the  sutures,  di- 
vided the  palato-pharyngeus  and  levator  palati,  and  then, 
if  the  edges  of  the  cleft  did  not  come  easily  together,  made 
two  lateral  oblique  cuts,  one  on  either  side,  above  the  higher 
suture,  separating,  to  a  limited  extent,  the  soft  from  the 
margin  of  the  hard  palate. 

Bonfils,  according  to  Dubrueil,  closed  an  opening  left  at 
the  upper  part  of  the  palate  by  the  partial  failure  of  an 
operation  for  staphyloraphy,  by  taking  a  flap  from  the  hard 
palate,  according  to  the  Indian  method  of  autoplasty  (q.  v  ). 


URANOPLASTY. 

Verneuil1  attributes  the  success  of  modern  uranoplastic 
operations  to  the  use  of  the  method  by  double  flaps,  ad- 
herent at  both  ends  and  brought  together  laterally  (lam- 
beaux  en  pont),  and  to  the  retention  of  the  periosteum  in 
the  flaps.  He  ascribes  the  first  use  of  double  flaps  to  Dief- 
fenbach,  and  thinks  the  retention  of  the  periosteum  was 
brought  about  by  Ollier's  most  valuable  experimental  and 
clinical  researches  upon  the  properties  of  this  tissue.  To 
Von  Langenbeck,  by  whose  name  the  method  is  usually 

1  Chirurgie  Reparatrice,  Art.  Uranoplastie. 


352  OPERATIVE  SURGERY. 

known,  he  gives  only  the  credit  of  being  the  first  to  adopt 
Ollier's  suggestion,  and  to  make  it  a  rule  of  practice. 

This  estimate  of  the  facts  does  not  seem  to  be  entirely 
correct.  It  is  true  that  Dieffenbach  used  double  lateral 
flaps,  but  a  large  part  of  the  success  of  the  modern  method 
is  due  to  the  greater  breadth  now  given  to  the  flaps.  Tillaux 
has  shown  that  the  branches  of  the  posterior  palatine  artery 
are  given  off  like  the  plumes  of  a  feather,  and  that  to  avoid 
division  of  these  branches,  and  insure  the  nutrition  of  the 
flap,  the  incision  must  be  made  close  to  the  alveolar  process. 
This  necessity  is  as  absolute  in  the  case  of  a  small  perfora- 
tion as  in  that  of  a  larger  one.  As  for  the  retention  of  the 
periosteum,  Von  Langenbeck  was  certainly  the  first  to 
point  out  its  importance  as  a  means  of  preventing  gangrene 
of  the  flap.  Ollier's  investigations  turned  upon  its  value 
in  favoring  reproduction  of  the  bone. 

Fissure  of  the  hard  and  soft  palate  endangers  an  infant's 
life  by  interfering  with  the  ingestion  of  food.  The  exact 
measure  of  this  danger  has  not  yet  been  established  by 
statistics,  but  it  is  certainly  considerable.1  On  the  other 
hand,  all  recorded  operations  for  cleft  palate  upon  children 
less  than  one  month  old  have  terminated  fatally,  aud  those 
undertaken  during;  the  first  five  or  six  months  of  the  ehild's 
life,  although  not  so  fatal,  show  but  few  successes.  Billroth 
aud  Simon  think  the  operation  should  be  performed  about 
the  eighth  month,  but  most  surgeons  are  agreed  upon  the 
propriety  of  postponing  it  until  the  third  or  fourth  year.  If 
a  child  has  lived  six  months  without  operation,  it  has  cer- 
tainly learned  to  overcome  the  mechanical  difficulties  in  the 
way  of  its  nourishment,  and  there  is,  consequently,  no  reason 
to  interfere  surgically  until  the  second  indication  arises. 
That  is  found  in  the  defective  articulation  and  phonatiou 
occasioned  by  the  lesion,  and,  as  children  with  cleft  palate 
do  not  begin  to  speak  before  the  third  or  fourth  year,  the 
operation  may  be  safely  postponed  until  that  time. 

The  special  instruments  required  are  a  speculum  oris,  or 
two  blunt  hooks  to  be  placed  at  the  angles  of  the  mouth  and 
fastened  together  by  a  rubber  band  passing  behind  the 
head,  pronged  forceps  with  long  handles,  curved  needles  of 

1  Lannelongue  i  M6m.  <ie  la  Boe.  de  Chirurgle,  wn,  p.  470. 


SPECIAL  OPERATIONS. 


353 


the  pattern  selected,  a  periosteum  elevator  bent  at  a  right 
angle  on  the  flat,  a  small  knife  similarly  bent,  and  sponges 
on  long  handles. 

The  edges  of  the  perforation  or  fissure  are  first  freshened 
by  the  removal  of  a  strip  one  or  two  millimetres  thick.  An 
incision  is  then  made  on  each  side  close  to  the  gum,  ex- 
tending from  the  last  molar  tooth  forward  as  far  as  maybe 
necessary,  and  exposing  the  bone  throughout.    The  elevator 

Fig.  202. 


Incisions  in  uranoplasty. 


is  introduced  into  this  incision  and  the  periosteum  separated 
from  without  inward,  care  being  taken  not  to  injure  the 
palatine  arteries  at  the  anterior  and  posterior  palatine  fora- 
mina. 

If  the  cleft  involves  the  soft  palate  its  sides  will  be  found 
to  round  off  toward  the  hamular  processes,  and  the  velum 


354  OPERATIVE  SUBGEBY. 

to  be  tightly  adherent  to  the  posterior  portion.  The  flaps 
cannot  be  brought  together  until  the  attachments  of  the  two 
halves  of  the  velum  at  these  points  are  entirely  separated, 
a  step  which  may  be  accomplished  by  meaus  of  a  small, 
curved,  sharp  elevator  introduced  through  the  lateral  in- 
cisions, or  by  the  bent  knife  introduced  through  the  fissure. 

The  bleeding  during  this  stage  of  the  operation  is  very 
free,  but,  as  Ehrmann1  has  remarked,  usually  ceases  as  soon 
as  the  flaps  are  completely  liberated.  If  it  continues  pres- 
sure should  be  made  for  a  few  moments  with  the  finger,  or 
ice  applied.  Trelat  carries  his  incisions  further  back,  stop- 
ping from  one-fourth  to  one-half  an  inch  behind  the  pos- 
terior border  of  the  hard  palate,  and  entirely  disregarding 
the  posterior  palatine  artery. 

The  flaps  are  brought  together  in  the  median  line  and 
the  sutures  applied,  beginning  at  the  anterior  extremity  of 
the  cleft.  The  sutures  should  be  left  in  at  least  four  days 
and  then  removed,  not  all  at  once,  but  by  instalments. 

If  the  fissure  is  unilateral,  the  vomer  remaining  attached 
on  the  other  side,  Von  Langenbeck  recommends  that  the 
lateral  incision  along  the  gum  should  be  made  only  upon  the 
side  occupied  by  the  fissure.  The  flap  on  the  other  side 
should  be  dissected  up  from  the  median  liue  outward. 

If  the  fissure  extends  through  the  dental  arch  and  is  wide 
at  the  point,  Rouge2  recommends  that  one  of  the  flaps  should 
be  detached  in  front  also  and  swung  in  sideways  upon  the 
posterior  attachment  as  a  centre. 

This  method  of  operating  has  practically  superseded  all 
others  for  closing  congenital  defects  in  the  hard  palate.  A 
great  number  have  been  proposed  and  more  or  less  exten- 
sively used,  but  are  now  so  seldom  resorted  to  that  only  a 
few  need  be  briefly  mentioned  for  purposes  of  reference. 

Sir  Win.  Fergusson's3  osteoplastic  method  consisted  in 
cutting  through  the  alveolar  margin  of  the  hard  palate  on 
each  side,  fracturing  the  anterior  extremity  of  the  strips  of 
bone  covered  with  their  muco-periosteum  and  uniting  them 
in  the  median  line.     Schonborn4   made  a  flap  base  down 

1  M6moires  de  l'Acad.  de  Medccinc,  vol.  xxxi. 

2  L'Uranoplastle  <?t  les  Divisions  Congfinit.  <lu  Palais,  1871,  p.  108. 
s  British  Med.  Jour.,  April  4,  1871. 

4  LariKcnbeck's  Archiv,  1870,  vol.  xix.  p.  527. 


SPECIAL  OPERATIONS.  355 

from  the  upper  part  of  the  posterior  wall  of  the  pharynx. 
It  comprised  all  the  soft  parts  in  front  of  the  vertebrae;  this 
was  turned  and  brought  forward  into  the  cleft.  Lanne- 
longue  turned  down  a  flap  of  muco-periosteum  from  each 
side  of  the  septum  of  the  nose  and  united  the  free  edges  to 
the  freshened  margins  of  the  gap  in  the  hard  palate. 

More  recently  Davies-Colley1  has  fashioned  muco-peri- 
osteal  flaps  of  nearly  equal  size  from  the  whole  of  the 
under  surface  of  the  rudimentary  palatine  processes  of  the 
superior  maxilla  and  palate  bones.  The  pedicle  of  flap 
No.  1  occupies  the  whole  length  of  one  side  of  the  cleft. 
The  pedicle  of  No.  2  corresponds  to  the  posterior  border 
of  as  much  hard  palate  as  exists  on  that  side.  No.  1  is 
turned  over  into  the  gap,  thus  placing  its  raw  surface  in- 
feriorly ;  No.  2  is  then  slid  over  this  raw  surface  as  far  as 
possible  without  tension,  and  sutured.  The  denuded  lat- 
eral areas  are  left  to  heal  by  granulation. 

Acquired  losses  of  substance  in  the  hard  palate,  if  of  any 
magnitude,  are  best  treated  by  an  "  obturator  "  or  vulcan- 
ized rubber  plate,  which  a  dentist  can  fit  into  the  roof  of 
the  mouth. 

EXCISION    OF   THE   TONGUE. 

Excisiou  of  the  tongue,  partial  or  complete,  may  be 
rendered  necessary  by  hypertrophy  of  the  organ  or  by  the 
presence  of  a  tumor.  The  hemorrhage  is  controlled  by 
ligation  of  the  vessels  as  they  are  divided  or  by  preliminary 
ligation  of  one  or  both  lingual  arteries.  Langeubuch2  has 
devised  a  method  of  so  placing  two  temporary  ligatures 
upon  the  tongue  that  bleeding  is  entirely  prevented  during 
the  removal  by  the  knife  of  any  portion  of  the  anterior 
half  or  even  two-thirds  of  the  member.  He  enters  the 
point  of  a  well-curved  needle  carrying  a  stout  ligature  a 
little  to  the  left  of  the  median  line  of  the  tongue  behind 
the  part  which  is  to  be  removed,  passes  it  deeply  down 
through  the  substance  of  the  tongue,  and  brings  it  out  on 
the  right  side  through  the  floor  of  the  mouth  so  as  to  in- 
clude the  branches  of  the  lingual  artery  in  its  loop.     To 

i  British  Med  Journ.,  October  25,  1890,  and  April  28,  1894. 
2  Archiv  fur  klinische  Chirurgie,  vol.  xxii.  part  I.,  1S78,  p.  72. 


356  OPERATIVE  SURGERY. 

prevent  slipping,  the  needle  is  then  passed  through  the 
edge  of  the  tongue ;  another  is  passed  in  the  same  manner 
on  the  opposite  side,  and  each  tied  tightly.  The  ends  may 
then  be  used  to  draw  the  tougue  forward. 

It  has  also  beeu  suggested  that,  when  it  is  necessary  to 
operate  very  far  back  upon  the  tongue,  its  base  can  be 
brought  forward  by  dislocating  the  lower  jaw  downward 
and  forward  simultaneously  on  both  sides. 

The  tongue  is  drawn  well  forward,  the  tumor  or  portion 
to  be  removed  seized  with  double-prouged  forceps  and 
rapidly  excised  by  a  V-shaped  incision  made  with  a  blunt- 
pointed  bistoury  so  as  to  avoid  injury  to  the  vessels  in  the 
floor  of  the  mouth  ;  all  bleeding  points  are  then  secured 
and  the  sides  of  the  wound  brought  together  with  sutures. 

If  a  larger  portion,  say  a  lateral  half,  of  the  tongue  is  to 
be  removed,  the  operation  may  be  done  as  follows  :  Two 
stout  ligatures  are  passed  through  the  tip,  one  on  each  side 
of  the  mediau  line,  to  be  used  to  draw  the  organ  forward ; 
the  tip  then  raised,  the  frsenum  cut  with  scissors,  and  the 
scissors  then  pushed  along  under  the  tougue  and  mucous 
membrane  to  free  them  as  far  back  as  necessary.  Then  the 
tongue  is  split  along  the  median  line,  from  before  backward, 
completely  freed  from  the  underlying  parts  by  tearing  with 
the  finger,  the  mucous  membrane  of  the  floor  divided  with 
the  scissors,  and  the  posterior  section  made  with  knife  or 
scissors. 

Complete,  through  the  Mouth. 

This  operation  has  been  extensively  employed  by  White- 
head,1  and  bears  his  name.  He  does  not  practise  a  pre- 
liminary ligation  of  the  lingual  arteries,  but  secures  them 
as  they  are  divided. 

The  mouth  is  made  as  aseptic  as  possible  and  the  face 
and  neck  shaved  and  cleaned.  The  lingual  artery  on  each 
side  is  ligated  ;  and  through  those  incisions,  which  may  be 
extended  if  necessary,  any  enlarged  or  suspicious  glands, 
including  one  or  both  submaxillaries,  are  removed.  The 
wounds  are  then  closed  and  dressed  antiseptically. 

After  this  the  patient's  head  is  placed  in  a  more  or  less 

i  Lancet,  1881,  vol.  i.  p.  698. 


SPECIAL  OPERATIONS.  357 

erect  position  with  a  slight  inclination  forward,  to  allow 
the  blood  to  escape  from  the  mouth.  The  jaws  are  held 
well  apart  with  a  suitable  mouth-gag  and  a  ligature  passed 
through  the  tongue  in  the  median  line  about  an  inch  from 
the  tip.  "With  this  the  tongue  is  drawn  out  and  up,  while 
first  the  frsenum  and  then  the  anterior  pillar  of  the  fauces 
are  divided  by  blunt-pointed  scissors.  With  short  snips 
of  the  scissors  all  the  muscles  with  the  overlying  mucous 
membrane  on  the  under  surface  of  the  tongue  are  cut  on  a 
plaue  with  the  lower  border  of  the  inferior  maxilla  and  as 
far  back  as  the  safety  of  the  epiglottis  permits.  It  may  be 
necessary  to  draw  the  lower  incisor  teeth  and  thus  gain 
more  room  for  manipulating  the  scissors.  The  tongue  is 
then  drawn  upward  by  the  ligature  passed  through  its  sub- 
stance and  the  posterior  section  completed  with  knife  or 
scissors.  The  dorsalis  linguse  vessels  can  be  readily  se- 
cured in  the  stump. 

Regnoli,s  Method.  Regnoli,  of  Pisa,  published  in  1838 
the  description  of  a  method  by  which  he  successfully  re- 
moved the  anterior  portion  of  the  tongue.  He  made  a 
semicircular  incision  through  the  skin  along  the  lower 
border  of  the  jaw,  beginning  and  ending  at  the  angles,  and 
added  a  second  one  to  it  in  the  median  line,  extending  to 
the  hyoid  bone.  The  tegumentary  flaps  were  dissected 
back,  and  the  muscles  divided  at  their  attachments  to  the 
inferior  maxilla.  The  tongue  was  then  drawn  down 
through  the  large  opening  thus  made,  its  anterior  portion 
readily  excised,  and  the  wound  closed.  Billroth  has  re- 
vived and  modified  Regnoli's  operation  and  employed  it  in 
several  cases.  It  has  the  advantage  of  furnishing  free 
drainage,  allowing  the  wound  to  be  treated  antiseptically, 
and  facilitating  the  removal  of  implicated  lymphatic  glands. 

Billroth's  Method.  A  semicircular  incision  is  made  along 
the  lower  border  of  the  inferior  maxilla  from  one  angle  to 
the  other.  The  flap,  containing  the  skin,  fascia,  and  pla- 
tysma,  is  dissected  back  and  the  lingual  arteries  tied  be- 
neath the  hyoglossus  muscle,  as  described  on  page  52. 

Enlarged  or  suspicious  glands,  including  the  submaxil- 
lary and  sublinguals,  are  dissected  out.     After  transfixing 

16* 


358 


OPERATIVE  SURGERY. 


the  tip  of  the  tongue  with  a  ligature  to  prevent  its  falling 
back  aud  closing  the  opening  of  the  larynx,  a  knife  is 
thrust  up  through  the  floor  of  the  mouth  close  behind  the 
symphysis  and  swept  backward  on  both  sides  as  far  as  the 
anterior  pillars  of  the  fauces.  It  should  divide  the  mucous 
membrane  and  muscles  attached  to  the  jaw  near  enough  to 
the  bone  to  clear  all  disease  and  yet  leave  sufficient  tissue 
to  permit  the  divided  muscles  to  be  at  least  partially 
sutured  in  position  again. 


Fig.  203. 


Removal  of  the  tongue.    K.  Kocher's  incision.    S.  Sedillot's  incision. 


After  the  attachments  of  the  geniohyoid,  gcniohyoglossus, 
and  digastric  muscles  have  been  severed,  together  witli  the 
anterior  part  of  the  hyoglossus,  the  tongue  is  drawn  out 
through  this  gap  and  excised.  A  drain  is  introduced,  the 
muscles  sutured  in  position,  and  the  wound  closed. 

Lateral  Supra-hyoid  Method.  Kocher1  (Fig.  203).  This 
method  has  for  its  object  the  very  thorough  removal  of  all 

i  Deutsche  Zeltscnrift  fllr  Chir.,  1880,  vol.  184. 


SPECIAL  OPERATIONS.  359 

diseased  tissues  of  the  tongue  and  pharynx  and  all  infected 
glands  in  the  neck.  Preliminary  laryngo-tracheotomy  is 
advantageous  to  facilitate  the  operation  and  permit  antisep- 
tic treatment  of  the  wound.  The  mouth  is  disinfected  by 
washing  with  a  salicylic  and  borax  solution. 

The  incision  is  made  from  the  under  border  of  the  lower 
jaw  near  the  symphysis,  in  the  direction  of  the  anterior 
belly  of  the  digastric,  to  the  hyoid  bone,  thence  backward  to 
the  anterior  border  of  the  sterno-cleido-mastoid,  and  then 
upward  along  it  to  or  above  the  angle  of  the  jaw;  after 
division  of  the  platysma  and  fascia  the  triangular  flap  is 
turned  up. 

The  submaxillary  fossa  is  then  emptied  by  removal  of  the 
submaxillary  and  diseased  lymphatic  glands,  the  facial  and 
lingual  arteries  and  veins  having  been  divided  between 
double  ligatures. 

The  larynx  and  oesophagus  are  then  covered  with  a 
sponge  forced  in  behind  the  tongue,  and  an  incision  made 
into  the  floor  of  the  mouth  by  cutting  through  the  mylo- 
hyoid muscle  close  to  the  jaw,  and  carried  along  the  bone  as 
far  as  may  be  neccessary. 

The  tongue  is  now  freely  accessible  through  the  wound, 
and  can  be  drawn  out  through  it  and  split,  and  cut  off  as 
near  its  base  as  is  desirable,  or  it  can  be  entirely  removed 
in  the  same  manner,  the  opposite  lingual  artery  being  readily 
secured  when  divided.  The  side,  and  even  the  posterior 
part  of  the  pharynx,  are  also  accessible. 

The  tracheotomy  tube  should  be  retained,  the  wound 
packed  with  antiseptic  gauze,  and  the  patient  fed  through 
an  oesophageal  tube. 

Sedillot,  commenting  upon  Regnoli's  case,  expresses  the 
opinion  that  the  excision  could  have  been  accomplished 
quite  as  readily  through  the  mouth,  and,  as  he  also  found 
by  experiments  upon  the  cadaver  that  the  tongue  cannot 
be  brought  far  enough  forward  through  such  an  opening  to 
facilitate  excision  at  or  near  its  base,  he  suggested  and  em- 
ployed division  of  the  inferior  maxilla  in  the  median  line 
as  a  preliminary  operation. 

_  Sedillot's  Method.     (Fig.  203.)     One  of  the  median  in- 
cisor teeth  on  the  lower  jaw  having  been  drawn,  an  incision 


360  OPERATIVE  SURGERY. 

is  made  in  the  median  line  from  the  free  border  of  the 
lower  lip  to  thehyoid  bone,  and  the  jaw  sawn  through  in  the 
line  of  the  incision,  or,  better,  by  two  oblique  lines  forming  a 
>,  the  apex  directed  to  one  side.  The  attachments  of  the 
genio-hyo-glossus  muscles  to  the  bone  are  next  divided,  the 
two  halves  of  the  jaw  drawn  apart,  the  tongue  pulled  for- 
ward and  to  one  side,  and  its  attachments  to  the  hyoid  bone 
divided  on  the  other  side,  in  doing  which  the  lingual  artery 
is  divided  and  must  be  tied  at  once.  The  tissues  on  the 
other  side  are  then  divided  in  a  similar  manner,  and  the 
other  lingual  artery  having  been  tied  the  remaining  attach- 
ments are  severed  and  the  tongue  removed. 

The  divided  maxilla  is  fastened  together  again  with  silver 
sutures  passed  through  holes  pierced  in  it  with  a  drill,  the 
sides  of  the  incision  in  the  lip  accurately  adjusted  to  each 
other,  and  the  lower  angle  of  the  wound  left  open  for 
drainage. 

The  bone  has  sometimes  been  divided  on  the  side  instead 
of  in  the  median  line. 

Von  Langenbeck  makes  an  incision  from  the  angle  of 
the  mouth  vertically  down  to  the  thyroid  cartilage.  Through 
this  the  submaxillary  and  lymphatics  are  extirpated,  the 
digastric  and  hyoglossus  muscles  cut  through,  the  lingual 
artery  tied,  and  the  jaw  sawn  obliquely  in  front  of  the  mas- 
seter  from  above  downward  and  backward.  After  drawing 
apart  the  segments  the  mucous  membrane  is  severed  from 
the  inner  surface  of  the  posterior  one  as  far  back  as  the 
anterior  pillar  of  the  fauces.  Through  this  gap  not  only 
the  tongue  but  also  the  tonsil  and  soft  palate  can  be  re- 
moved if  necessary.  The  operation  is  concluded  like  Sedil- 
lot's. 

Billroth's  modification  of  this  consists  in  dividing  the 
jaw  and  overlying  soft  parts  on  both  sides,  and  turning 
down  the  intermediate  chin  segment. 

Crespi  and  Bastianelli1  have  still  further  modified  Lang- 
enbeck's  operation  as  follows:  An  incision  is  carried  ver- 
tically down  through  the  middle  of  the  under  lip  and  chin 
to  the  lower  border  of  the  jaw,  along  the  latter  horizon- 
tally to  near  the  angle,  and  thence  vertically  down    for 

1  Contrail),  f,  chir.,  L890,  p.  556, 


SPECIAL  OPERATIONS.  361 

about  an  inch  to  the  anterior  border  of  the  sterno-mastoid 
muscle.  The  soft  parts  are  separated  from  the  outer  sur- 
face of  the  jaw  to  within  an  inch  of  the  insertion  of  the 
masseter,  the  facial  and  lingual  arteries  ligated,  the  salivary 
and  lymphatic  glands  removed,  and  the  jaw  divided  ob- 
liquely from  behind  forward  in  front  of  the  second  molar 
tooth.  This  affords  access  to  the  retrobuccal  and  pharyn- 
geal region,  and  permits  of  removal  of  the  tonsil  and  ad- 
joining parts. 

DIVISION   OF   THE    FRUSTUM. 

The  tip  of  the  tongue  is  raised  upon  the  handle  of  a 
director,  in  the  slit  of  which  the  frsenum  is  engaged,  and 
divided  with  curved  scissors  close  to  the  director.  Only 
the  semi-transparent  edge  of  the  constricting  band  should 
be  cut,  and  then  the  rest  torn  by  pressing  the  tongue  up 
toward  the  roof  of  the  mouth.  If  the  ranine  vessels  should 
chance  to  be  divided  the  bleeding  can  be  controlled  by  tor- 
sion or  ligation  or  by  touching  the  points  with  nitrate  of 
silver,  or,  if  necessary,  with  the  actual  cautery.  J.  L.  Petit 
reported  a  case  of  suffocation  caused  by  the  tongue  falling 
back  upon  the  glottis  after  division  of  the  frsenum,  aud 
GuSrin  mentions  another. 


RANULA. 

The  anterior  wall  of  the  cyst  should  be  caught  up  with 
toothed  forceps  and  excised.  A  director  should  be  passed 
at  intervals  between  the  sides  of  the  incision  to  prevent  re- 
union, and  the  filling  up  of  the  sac  may  be  hastened  by 
painting  its  interior  with  nitric  acid  or  tincture  of  iodine. 
In  some  cases  it  is  sufficient  to  pass  a  thread  or  wire  setou 
through  the  cyst. 

SALIVARY    FISTULA. 

Salivary  fistula  communicating  directly  with  portions  of 
the  parotid  gland  can  usually  be  closed  by  cauterization 
and  compression,  but  when  the  fistula  communicates  with 


362  OPERATIVE  SURGERY. 

Steno's  duct  the  cure  is  much  more  difficult.  If  the  distal 
portion  of  the  duct  is  still  permeable  a  leaden  wire  may  be 
passed  through  it  from  the  mouth  into  the  proximal  por- 
tion of  the  duct.  The  saliva  will  follow  the  wire,  and  if 
the  fistula  does  not  close  spontaneously  its  edges  should  be 
pared  and  brought  together  with  sutures.  The  orifice  of 
the  duct  is  readily  found  opposite  the  second  upper  molar 
tooth. 

When  the  distal  portion  of  the  duct  is  obliterated  sev- 
eral methods  may  be  employed.  One  is  that  of  Deguise, 
and  consists  in  the  formation  of  a  new  channel  in  the  cheek 
for  the  saliva  ;  another  is  that  of  Professor  Van  Buren, 
and  consists  in  the  bodily  transfer  of  the  fistulous  orifice 
from  the  outer  to  the  inner  surface  of  the  cheek. 

Deguise's  Method.  Deguise  made  a  puncture  through 
the  fistulous  opening  obliquely  backward  to  the  inner  sur- 
face of  the  cheek  and  passed  one  end  of  a  leaden  wire 
through  it;  he  next  made  through  the  same  opening  a 
second  puncture  directed  obliquely  forward,  brought  the 
other  end  of  the  wire  through  it  and  tied  the  two  ends 
together.  The  loop  of  the  wire  being  thus  drawn  into  the 
fistula  the  saliva  followed  its  two  branches  into  the  mouth, 
and  the  fistula  healed  at  once.  Some  surgeons  use  a  silk 
ligature  and  tie  it  tightly  so  as  to  cut  through  the  tissues 
included  in  the  loop.  Agnew's  method  of  doing  this  is 
by  the  passage  of  a  curved  needle  around  the  duct  from 
within  the  mouth. 

Prof.  Van  Buren1  cured  a  salivary  fistula,  the  result  ot 
a  gunshot  wound,  by  passing  two  fine  silver  wires  through 
the  skin  at  opposite  points  on  its  edge,  then  isolating  the 
duct  and  fistulous  opening  for  half  an  inch  by  dissection 
backward  from  the  latter,  making  an  incision  through  the 
wound  to  the  inner  side  of  the  cheek,  drawing  the  fistulous 
opening  through  it,  and  fastening  it  there  by  means  of  the 
wires.  The  gap  left  on  the  cheek  was  then  closed  with  fine 
silver  sutures. 

1  New  York  Medical  .Journal,    vol.   i.  j>.  58,   and   Contributions  to   Practical 
Surgery,  1865,  i>.  '20.r>. 


SPECIAL  OPERATIONS.  363 

The  duct  was  so  short,  the  fistula  being  an  inch  behind 
the  anterior  margin  of  the  masseter,  that  it  could  not  be 
brought  quite  to  the  iuner  surface  of  the  cheek.  The  wires, 
however,  which  were  left  in  place  uutil  the  fifth  week,  kept 
open  a  track,  which  became  permanent,  for  the  passage  of 
the  saliva  from  the  end  of  the  duct  to  the  mouth. 


CHAPTER    IV. 

OPERATIONS  PERFORMED  UPON  THE  NECK. 
BRONCHOTOMY. 

This  is  a  general  term  covering  operations  undertaken 
to  open  the  larynx  or  cervical  portion  of  the  trachea.  These 
operations  are :  Laryngotomy,  tracheotomy,  aud  laryngo- 
tracheotomy.  Laryngotomy  is  further  subdivided  into  sub- 
hyoid pharyngotomy,  or  laryngotomy  (called  supra-laryn- 
geal  bronchotomy  by  Seclillot,  and  indirect  laryngotomy  by 
Planchou),  thyroid  laryngotomy  or  thyrotomy,  crico-thyroid 
laryngotomy,  and  tracheotomy,  which  is  further  subdivided 
into  high  and  low,  dependiug  upon  whether  the  trachea  is 
opened  above  or  below  the  isthmus  of  the  thyroid  gland. 
The  names  indicate  the  points  at  which  the  opening  is 
made  into  the  air-passages. 

Sub-hyoid  Pharyngotomy  or  Laryngotomy.  This  opera- 
tion, origiually  performed  upon  animals  by  Bichat  for  the 
purpose  of  studying  the  movements  of  the  vocal  cords, 
was  afterward  proposed  by  Vidal  to  give  access  to  an 
abscess  situated  in  the  glotto-epiglottidean  folds,  and  by 
Malgaigue  to  allow  the  removal  of  a  foreign  body  lodged 
iu  the  upper  part  of  the  larynx.  It  is  also  applicable  to 
the  removal  of  polyps  situated  at  the  same  point  and  not 
accessible  through  the  mouth.  Folliu  thus  removed  ten 
from  the  anterior  surface  of  the  arytenoid  cartilages. 

The  shoulders  are  raised  and  the  head  extended.   A  trans- 


364  OPERATIVE  SURGERY. 

verse  incision  two  inched  long,  its  centre  in  the  median 
line,  is  made  through  the  skin  immediately  below  the  hyoid 
bone,  and  the  platysma,  sterno-hyoid,  and  thyro-hyoid  mus- 
cles, and  thyro-hyoid  membrane  divided.  The  mucous 
membrane  lying  between  the  epiglottis  and  the  base  of  the 
tongue  then  presents  in  the  incision,  is  drawn  downward 
with  forceps,  and  opened  with  the  knife  or  scissors.  The 
epiglottis  is  then  seized  with  a  hook  or  pronged  forceps 
and  drawn  out  through  the  wound,  freely  exposing  the 
larynx  to  view. 

Velpeau  made  the  first  incision  in  the  median  line, 
divided  the  thyro-hyoid  membrane  transversely,  and  then 
plunged  the  knife  backward  and  downward,  making  a  ver- 
ical  incision  in  the  base  of  the  epiglottis  through  which 
he  passed  the  blades  of  a  pair  of  forceps  and  withdrew  the 
foreign  body. 

Aplavin1  has  modified  this  operation  as  follows :  With 
the  head  well  extended  the  trachea  is  opened  and  plugged 
by  a  tampon-canula — a  tracheotomy  tube  surrounded  by  a 
rubber  bag,  which  is  inflated  after  its  introduction  till  it 
fills  the  lumen  of  the  trachea.  The  pharynx  is  incised 
transversely  as  above  described  and  the  hyoid  bone  cut 
through  with  scissors  on  each  side  from  one-half  to  three- 
quarters  of  an  inch  in  front  of  its  extremities.  If  there 
is  fear  of  wounding  the  lingual  vessels  a  part  of  the  hyo- 
glossus  muscle  is  cut  close  above  the  hyoid  bone  and  the 
vessels  recognized  and  drawn  up.  By  raising  this  segment 
of  bone  and  depressing  the  thyroid  cartilage,  pretty  free 
access  can  be  obtained  to  the  parts  close  around  the  open- 
ing of  the  larynx. 

At  the  conclusion  of  the  operation  the  mucous  mem- 
brane is  sutured  first ;  then  external  to  it  a  silk  suture  is 
passed  on  each  side  through  the  skin  and  upper  border  of 
the  thyroid  cartilage  behind  and  over  the  hyoid  bone  about 
one-half  an  inch  in  front  of  its  points  of  division.  After 
uniting  the  thyro-hyoid  membrane  and  overlying  soft 
parts  the  two  silk  ligatures  are  knotted  externally  and  thus 
prevent  undue  tension  on  the  other  sutures. 

1  Arcblv  r.  kiln.  Chlr.,  vol.  n,  i>.  824. 


SPECIAL  OPERATIONS  365 

Thyroid  Laryngotomy  or  Thyrotomy.  In  this  operation 
the  thyroid  cartilage  is  divided  vertically  in  the  median 
line,  between  the  anterior  attachments  of  the  vocal  cords. 
It  is  suitable  for  the  removal  of  foreign  bodies  or  polyps 
from  the  interior  of  the  larynx  and  for  fractures,  stenosis, 
or  disease  of  this  organ. 

The  head  is  well  extended,  or  allowed  to  hang  from  the 
edge  of  the  table.  A  preliminary  tracheotomy  and  plug- 
ging of  the  trachea  may  be  necessary. 

Steadying  the  larynx  with  the  thumb  and  forefinger  of 
his  left  hand,  the  surgeon  makes  an  incision  along  the  pro- 
jecting angle  of  the  thyroid  cartilage  in  the  median  line, 
from  its  upper  border  to  the  cricoid  cartilage.  As  soon  as 
the  crico-thyroid  membrane  is  exposed,  he  makes  a  small 
opening  in  it  near  its  upper  border  and  passes  one  blade  of 
a  strong  blunt-pointed  pair  of  scissors  through  it  to  the 
upper  border  of  the  laryux,  keeping  exactly  in  the  median 
line,  and  thus  divides  the  thyroid  cartilage  throughout  its 
entire  length.  Or  a  grooved  director  may  be  passed  through 
the  opening  made  in  the  crico-thyroid  membrane,  and  the 
cartilage  divided  upon  it  with  a  curved  bistoury.  Or, 
again,  the  division  may  be  made  with  the  knife,  layer  by 
layer,  from  before  backward;  but  whenever  possible  the 
upper  border  of  the  larynx  should  be  left  uncut  to  preserve 
the  relation  of  the  vocal  cords. 

The  conoid  and  thyro-hyoid  ligaments  and  thyro-hyoid 
membrane  must  often  be  separated  to  a  greater  or  less 
extent  from  the  upper  and  lower  border  of  the  thyroid 
cartilage  to  permit  its  lateral  halves  to  be  retracted  suffi- 
ciently to  expose  thoroughly  the  cavity  of  the  larynx. 

At  the  conclusion  of  the  operation  the  wound  may  either 
be  closed  immediately  with  silk  or  silver-wire  sutures,  or 
left  open  and  packed  for  a  couple  of  days. 

Crico-thyroid  Laryngotomy.  In  this  operation  the  open- 
ing is  made  in  the  crico-thyroid  membraue.  The  French 
writers,  Sedillot,  Dubrueil,  Chauvel,  speak  of  this  method 
as  having  been  entirely  abandoned  because  the  opening 
cannot  be  made  sufficiently  large.  Holmes,  on  the  other 
hand,  considers  it  suitable  in  all  cases  in  which  only  the 
vocal  cords  or  the  tissues  above  them  are  involved,  and  says 


366  OPERA TIVE  S UR OER  Y. 

it  is  practised  in  spasm  of  the  glottis  from  any  cause,  in 
erysipelatous  affections  spreading  down  the  throat,  and  in 
cases  of  foreign  body  lodged  in  or  above  the  glottis.  If 
the  opening  proves  to  be  too  small  it  cau  be  enlarged  down- 
ward through  the  cricoid  cartilage  (laryngo-tracheotomy). 
The  operation  may  be  required  in  cases  of  urgency  when 
no  tube  is  at  hand.  A  pair  of  forceps  or  scissors,  a  hair- 
pin, or  pieces  of  bent  wire  will  suffice  to  keep  the  wound 
open,  and  the  incision  can  be  made  with  the  penknife. 

Operation.  Dorsal  decubitus,  shoulders  raised  upon  a 
cushion  or  narrow  pillow  so  that  the  head  may  fall  back 
aud  keep  the  throat  tense.  The  surgeon,  standing  at  the 
patient's  right  side,  fixes  the  larynx  with  his  left  thumb  and 
middle  finger  placed  on  either  side,  and  the  index  upon  its 
upper  border,  and  makes  a  cutaneous  incision  in  the  median 
line  corresponding  to  the  crico-thyroid  membrane.  He  draws 
the  sterno-thyroid  muscles  apart,  lays  bare  the  membrane, 
and  divides  it  transversely  or  vertically  ;  in  the  latter  case 
the  incision  should  begin  a  short  distance  below  the  inferior 
border  of  the  thyroid  cartilage,  so  as  to  avoid  a  small  artery 
which  crosses  at  that  point,  and  extend  to  the  cricoid 
cartilage.  (For  the  method  of  inserting  the  canula,  see 
Tracheotomy.) 

Laryngo-tracheotomy.  The  opening  occupies  part  of  the 
crico-thyroid  membrane,  the  cricoid  cartilage,  and  the  first 
two  or  three  rings  of  the  trachea.  The  upper  border  of 
the  isthmus  of  the  thyroid  usually  corresponds  to  the 
second  ring  of  the  trachea  ;  it  should  not  be  divided.  In 
children  under  six  years  it  commonly  rises  to  the  lower 
border  of  the  cricoid  cartilage. 

Dorsal  decubitus,  with  shoulders  raised,  head  thrown 
back,  and  neck  slightly  stretched.  The  larynx  is  fixed  as 
for  crico-thyroid  laryngotomy,  and  an  incision  made  through 
the  skin  exactly  in  the  median  line  from  the  middle  of  the 
thyroid  cartilage  to  about  one  inch  below  the  cricoid.  The 
muscles  arc  carefully  drawn  apart,  the  isthmus  of  the  thy- 
roid depressed  if  necesary,  after  nicking  and  tearing  with 
blunt  hooks  the  suspensory  fascia  at  its  upper  border,  the 
trachea  steadied   aud   drawn   upward    with   a  sharp  hook 


SPECIAL  OPERATIONS.  367 

thrust  into  the  upper  part  of  the  crico-thyroid  membrane, 
and  the  point  of  the  bistoury  entered  close  below  the  hook 
and  made  to  cut  downward  through  the  cricoid  cartilage 
and  one  or  two  of  the  rings  of  the  trachea.  The  edges  of  the 
incision  are  then  held  apart  and  the  cauula  introduced,  or 
the  forceps  if  the  operation  has  been  undertaken  with  a 
view  to  the  removal  of  a  foreign  body  or  a  polyp. 

De  Saint  Germain's  Method.  Dorsal  decubitus,  shoul- 
ders raised,  neck  extended.  The  surgeons  feels  for  the 
cricoid  and  thyroid  cartilages,  and  the  depression  between 
them.  Then,  standing  upon  the  patient's  right  side,  he 
places  his  left  thumb  and  middle  finger  on  either  side  of 
the  larynx,  and  by  pressing  them  in  between  it  and  the 
vertebral  column,  pushes  the  larynx  forward,  makes  tense 
the  skin  covering  it,  and  at  the  same  time  marks  the  situa- 
tion of  the  lower  border  of  the  thyroid  cartilage  with  the 
nail  of  his  left  forefinger. 

The  knife,  a  straight,  sharp-poiuted  bistoury,  is  held  like 
a  pen,  its  back  directed  upward,  and  the  middle  finger  so 
placed  upon  its  side  as  to  limit  to  half  an  inch  the  depth 
to  which  the  point  can  penetrate.  It  is  then  entered  with 
a  quick  sharp  stab  in  the  median  line  close  against  the  nail 
of  the  left  forefinger  and  made  to  cut  downward  with  a 
sawing  motion  through  the  cricoid  cartilage  and  one  or  two 
tracheal  rings,  care  being  taken  to  make  the  incision  in 
the  skin  fully  as  long  as  that  in  the  trachea.  The  wound 
is  held  open  with  a  "dilator,"  and  the  canula  introduced 
between  its  branches;  the  pressure  of  the  latter  is  usually 
sufficient  to  arrest  hemorrhage,  but  ligatures  cau  be  easily 
applied  if  necessary.  In  only  oue  case  out  of  ninety-seven 
did  Saint  Germain  injure  the  posterior  wall  of  the  trachea, 
and  in  only  three  did  hemorrhage  occur.1 

Tracheotomy.  The  trachea  may  be  opened  at  any  point 
between  the  cricoid  cartilage  and  the  upper  border  of  the 
sternum,  a  distance  averaging  in  the  adult  from  two  and 
one  half  to  three  inches,  in  the  child  under  ten  years  of  age 
from  one  and  one-half  to  two  and  one-half  inches.     Its 

1  Bull,  de  la  Societe  de  Chirurgie,  1877,  pp.  271  and  327. 


368  OPERA TIVE  S UEOER  Y. 

course  is  obliquely  backward  as  well  as  downward,  so  that 
while  its  upper  end  is  almost  subcutaneous  it  becomes 
deeply  placed  before  it  passes  behind  the  sternum.  It  is 
crossed  at  its  upper  eud  by  the  isthmus  of  the  thyroid 
glaud,  the  breadth,  thickness,  and  vascularity  of  which 
vary  within  very  wide  limits,  although  its  upper  border 
usually  corresponds  to  the  second  ring  of  the  trachea.  A 
communicating  branch  uniting  the  two  inferior  thyroid 
arteries  crosses  just  below  the  lower  border  of  the  isthmus. 
The  lower  portion  is  covered  anteriorly  by  the  thyroid 
veins,  always  greatly  distended  when  the  respiration  is  ob- 
structed, and  by  the  thymus  glaud  in  children  under  two 
years  of  age,  and  occasionally  in  unhealthy  older  ones 

To  the  dangers  depending  upon  the  normal  arrangement 
of  the  parts  are  added  those  of  not  infrequent  anomalies  in 
the  origin  and  course  of  the  arteries  and  veins.  Thus,  the 
left  brachio-cephalic  vein  may  cross  the  trachea  well  above 
the  sternum,  the  left  carotid  may  arise  from  the  innominate, 
and  sometimes  a  thyroidea  ima  artery  is  given  off  from  the 
transverse  portion  of  the  arch  of  the  aorta,  and  ascends 
along  the  anterior  surface  of  the  trachea  in  the  median  line. 
Finally,  an  aneurism  of  the  innominate,  or  of  the  arch  of 
the  aorta,  may  rise  in  front  of  this  portion  of  the  trachea. 

Operation.  The  patient  is  placed  upon  his  back  with 
shoulders  raised  and  head  thrown  back.  A  trustworthy 
assistant,  standing  behind  the  head,  holds  it  firmly  in  a 
straight  line  with  the  body;  others  control  the  patient's 
limbs  if  he  has  not  been  anaesthetized.  The  surgeon,  stand- 
ing at  the  patient's  right  side,  recognizes  with  his  finger  the 
hyoid  bone  aud  thyroid  and  cricoid  cartilages,  and,  marking 
with  his  left  forefinger  the  upper  border  of  the  cricoid 
cartilage,  makes  an  incision  downward  from  it  in  the 
median  line  from  one  and  one-half  to  two  inches  in  length, 
according  to  the  size  of  the  patient.  He  carries  the  incision 
through  the  skin  and  fascia,  separates  the  sterno-hyoid  and 
sterno-thyroid  muscles  with  the  handle  of  his  knife,  and 
lays  bare  the  isthmus  of  the  thyroid.  If  any  large  veins 
are  encountered,  they  must  be  carefully  drawn  aside  or  di- 
vided between  two  ligatures,  but  bleeding  from  smaller 
ones  may  be  safely  disregarded,  for,  as  Trousseau  pointed 
out,  it  will  cease  as  soon  as  the  trachea  is  opened,  and  the 


SPECIAL  OPERATIONS. 


369 


venous  congestion  relieved  by  the  admission  of  air  to  the 
luugs. 

It  is  well  to  have  one  or  two  assistants  hold  the  sides  of 
the  incision  apart  during  the  dissection,  if  they  can  be  de- 
pended upon  to  do  so  without  disturbing  the  relations  of  the 
parts  by  drawing  too  forcibly  toward  one  side  or  the  other. 

The  isthmus  of  the  thyroid  is  next  drawn  upward  with 
a  blunt  hook,  and  three  or  four  rings  of  the  trachea  exposed 
below  it,  and  divided  from  below  upward.  If  for  any 
reason  it  is  desirable  to  make  the  incision  higher  up,  or  if 
the  isthmus  is  unusually  broad,  it  may  be  divided  between 
two  ligatures,  in  which  case  the  incision  of  the  trachea 
should  be  made  from  the  lower  border  of  the  cricoid  carti- 
lage downward. 


Fig.  204. 


Fig.  205. 


Bivalve  canula  closed.       Bivalve  eanula  with  tube  in  place. 


The  incision  in  the  trachea  should  always  be  free  enough 
to  admit  the  canula  readily,  and  should  be  made  by  a  quick 
thrust  with  a  sharp-pointed  knife,  which  must  be  prevented 
from  penetrating  too  deeply  at  first,  by  holding  it  close  to 
its  point.  After  the  puncture  has  been  thus  made,  it  is  en- 
larged by  gentle  sawing  movements  of  the  knife,  or  with 
scissors. 

The  knife  is  retained  in  the  trachea  as  a  guide,  until  the 
dilator  or  bivalve  canula  (Figs.  204  and  205)  has  been  in- 
troduced. The  best  dilator  is  the  three-bladed  one ;  it  is 
introduced  closed,  its  blades  then  expanded,  and  the  perma- 


370  OPERATIVE  SURGERY. 

nent  canula  passed  in  between  them.  The  canula  should  be 
curved,  double  to  facilitate  cleaniug,  and  provided  with  an 
opening  on  its  convexity  through  which  the  expired  air  can 
pass  to  the  larynx. 

Some  surgeons  steady  the  trachea  by  drawing  it  toward 
the  chin  with  a  tenaculum  introduced  at  the  lower  edge  of 
the  cricoid  cartilage.  Gurdon  Buck  used  for  this  purpose 
a  rather  narrow  lance-shaped  knife,  bent  at  a  right  angle  on 
the  flat,  and  also  grooved  on  the  back  for  use  as  a  director. 

Galoano-  or  Thermo-cautery.  The  danger  of  hemor- 
rhage, especially  in  the  adult,  has  led  many  surgeons  to  use 
the  galvano-  or  thermo-cautery.  Its  hemostatic  advantages, 
however,  are  offset  by  a  large  eschar  which  it  causes,  and 
the  possible  necrosis  of  the  tracheal  cartilages.1  The  cautery 
should  be  used  only  to  divide  the  soft  parts,  the  trachea 
should  be  opened  with  the  knife.  Saint  Germain  has  also 
sought  to  prevent  hemorrhage  by  making  the  incision  with 
a  red-hot  bistoury. 


LARYNGECTOMY/ 

Complete.  A  preliminary  tracheotomy  is  necessary.  A 
pad  is  placed  under  the  shoulders  and  the  head  thrown  well 
back.  The  incision  is  in  the  median  line,  and  extends 
from  the  thyro-hyoid  space  to  the  second  or  third  tracheal 
ring.  A  transverse  incision  joins  this  at  the  upper  end  and 
passes  outward  parallel  to  the  hyoid  bone  as  far  as  each 
sterno-mastoid  muscle.  The  skin,  fascia,  and  platysma  are 
drawn  aside  and  the  superior  thyroid  arteries  secured  at  the 
posterior  margin  of  the  thyro-hyoid  muscle  beneath  the 
sterno-hyoid  close  to  the  upper  border  of  the  thyroid  carti- 
lage. Next  the  inferior  thyroid  arteries  are  ligated  below, 
beneath  the  posterior  edge  of  the  sterno-thyroid  muscles. 

By  means  of  a  periosteal  elevator  or  blunt-pointed  scis- 
sors entered  beneath  the  fascia  in  the  middle  line  the  crico- 
thyroid, sterno-thyroid,  and  thyro-hyoid  muscles  on  each  side 
are  detached  and  retracted  with  the  other  soft  parts.     The 

1  See  the  discussion  in  the  Soei6t6  de  Chirurgie,  May  9  to  June  13,  1877. 
-  Hahn.  Volkraann's  Sammluntf,  1885,  No.  260. 


SPECIAL  OPERATIONS.  371 

thyroid  cartilage  is  drawn  first  to  one  side  and  then  to  the 
other,  and  the  inferior  constrictor  muscle  separated.  All 
cutting  should  be  done  with  the  blunt-pointed  scissors  kept 
close  to  the  cartilages.  The  superior  laryngeal  nerves  and 
the  thyro-hyoid  membranes  and  ligaments  are  divided,  the 
epiglottis  drawn  out  and  its  extra-laryngeal  attachments  cut. 
The  larynx  is  next  pulled  forward  and  separated  from  any 
remaining  connection  with  the  pharynx  or  oesophagus  to  a 
point  just  below  the  cricoid  cartilage.  Great  care  is  neces- 
sary to  avoid  opening  the  oesophagus.  The  trachea  is 
secured  from  slipping  down  by  a  temporary  suture  on  each 
side  and  is  cut  across  below  the  cricoid  cartilage.  The 
divided  end  is  secured  at  the  surface  in  the  wound  with  in- 
terrupted silk  sutures  and  the  mucous  membrane  sutured 
to  the  margins  of  the  skin  incision. 

When  there  is  doubt  about  the  extent  of  the  laryngeal 
disease,  immediately  after  the  vertical  skin  incision  the 
thyroid  cartilage  should  be  split  in  the  middle  line.  This 
is  done  by  steadying  the  larynx  and  cutting  from  before 
backward  with  the  knife  or  from  below  upward  with  a 
blunt-pointed  scissors  entered  through  the  crico-thyroid 
membrane.  If  then  on  inspection  it  is  found  that  the  whole 
larynx  must  be  sacrificed  the  operation  is  proceeded  with 
as  already  described.  It  is  usually  recommended  to  remove 
the  cricoid  cartilage  in  all  cases  of  total  extirpation,  as  it  is 
of  no  functional  value  and  its  retention  interferes  with  the 
act  of  swallowing. 

Partial.  The  vertical  skin  incision  in  the  median  line 
is  employed  as  in  total  laryngectomy.  At  the  upper  end 
of  the  vertical  incision  a  horizontal  incision  passes  out 
from  it  parallel  to  and  just  below  the  hyoid  bone  on  the 
affected  side  as  far  as  the  steruo-mastoid  muscle.  This  in- 
volves the  skin,  fascia,  and  platysma.  The  thyroid  carti- 
lage is  then  divided  vertically  exactly  in  the  mediau  line 
with  the  knife  or  scissors. 

After  separation  of  the  alse  M.  Buttin1  advises,  if  the 
disease  ic  of  limited  extent,  that  it  be  cut  away,  with  a  wide 
margin  of  healthy  tissue,  meaning  that  it  be  scooped  out  of 

1  Op.  Surg.  Malig.  Disease, 


372  OPERATIVE  SURGERY. 

the  concavity  of  the  ala  with  the  surrounding  mucous 
membrane.  The  ala  of  the  thyroid  is  then  restored  to 
its  place.  M.  Buttin  claims  that  cancer  does  not  infil- 
trate the  cartilage,  and  therefore  it  is  only  necessary  to 
scrape  and  cauterize  the  part  adjacent  to  the  disease. 

If  one-half  of  the  thyroid  cartilage  must  be  removed, 
the  steruo-thyroid  muscle  is  cut  at  its  upper  end  and  laid 
back.  The  thyrohyoid,  steruo-thyroid,  and  crico-thyroid 
muscles  are  carefully  detached  with  the  elevator  or 
blunt-pointed  scissors.  The  thyroid  and  crico-thyroid 
membranes  and  superior  laryngeal  nerve  are  cut  close  to 
the  cartilage,  and  any  vessels  are  secured  as  they  are 
divided.  The  superior  cornu  of  the  thyroid  cartilage  is 
cut  through  at  its  base.  The  whole  or  part  of  the  epi- 
glottis is  left  and  the  aryteno-epiglottic  fold  of  mucous 
membrane  spared  as  much  as  possible.  The  pharyngeal 
wall  must  be  freed  with  great  care.  The  inferior  cornu 
is  divided,  any  remaining  attachments  severed  with  short 
snips  of  the  scissors  and  the  ala  removed. 

The  parts  are  then  sutured  in  their  proper  positions  as 
nearly  as  possible  after  placing  over  the  denuded  surface 
all  the  mucous  membrane  obtainable. 


PHARYNGOTOMY. 

This  is  an  operation  required  for  the  removal  of  foreign 
bodies  or  diseases  from  the  pharynx  or  immediately  ad- 
joining parts  which  are  not  accessible  through  the  mouth. 
Langenbeck's  (page  361),  or  the  Crespi-Bastianelli  methods 
(page  361),  for  reaching  the  base  of  the  tongue  are  also 
useful  for  exposing  the  tonsil  and  posterior  pharyngeal 
wall.  Aplavin's  sub-hyoid  pharyngotomy  (page  365)  gives 
a  somewhat  limited  view  of  the  parts  around  the  entrance 
to  the  larynx. 

Gaps  left  after  excision  of  portions  of  the  walls  of  the 
pharynx  must  be  left  to  granulate;  if  the  epiglottis  has 
been  disturbed  its  attachments  must  as  far  as  possible  be 
replaced  and  sutured  in  their  proper  position. 


SPECIAL  OPERATIONS.  373 

Von  LangenbecFs  Method.1  After  a  preliminary  trache- 
otomy the  head  is  extended  and  chiu  turned  to  the  side  oppo- 
site to  the  one  in  question.  The  incision  extends  from  the 
middle  of  the  lower  border  of  the  horizontal  ramus  of  the 
inferior  maxilla  downward  across  the  greater  cornu  of  the 
hyoid  bone  along  the  posterior  border  of  the  thyro-hyoid 
muscle  to  the  cricoid  cartilage  or  a  little  further.  After 
division  of  the  superficial  fascia,  platysma,  and  omohyoid, 
the  lingual,  and  superior  thyroid  arteries  and  facial  vein 
are  cut  and  secured.  Both  branches  of  the  superior  laryn- 
geal nerve  are  divided.  After  freeing  the  attachments  of 
the  digastric  and  stylo- hyoid  from  the  hyoid  bone  the 
pharynx  is  laid  open  through  the  whole  length  of  the 
wound.  The  thyroid  cartilage  can  be  turned  on  its  long 
axis  so  that  its  posterior  surface  is  visible  in  the  wound 
and  the  pharynx  is  accessible  as  high  as  the  soft  palate. 

Another  method  of  the  same  surgeon's  is  as  follows  :  A 
U-shaped  flap  of  skin  and  subcutaneous  tissue  is  made,  the 
base  of  which  is  above  and  corresponds  in  width  to  the 
length  of  the  zygoma.  Its  sides  and  bottom  follow  the 
auterior  border  of  the  masseter  muscle,  the  posterior  border 
of  the  ramus,  and  the  intervening  portion  of  the  lower 
border  of  the  jaw,  respectively.  The  inferior  maxilla  is 
sawn  through  in  front  of  the  insertion  of  the  masseter,  and 
the  ramus  dislocated  by  turning  it  outward  and  upward. 

Butliu2  describes  an  operation  by  Czerny,  which  is  vir- 
tually the  same  as  Von  Langenbeck's  for  excision  of  the 
tongue.  The  incision  extends  from  the  angle  of  the  mouth 
to  the  extremity  of  the  hyoid  bone,  and  the  jaw  is  sawn 
through  obliquely  from  above  and  without  downward  and 
inward  between  the  second  and  third  molar  teeth. 

Mikulicz's  Method?  After  a  preliminary  tracheotomy 
and  plugging  of  the  fauces  or  larynx  an  incision  is  made 
from  the  tip  of  the  mastoid  process  to  the  level  of  the 
greater  cornu  of  the  hyoid  bone.  The  periosteum  and 
overlying  parts  are  raised  from  the  outer  and  inner  surface 
of  the  ascending  ramus  of  the  inferior  maxilla,  special  care 

1  Archiv  f.  klin.  Chir.,  1879,  Bd.  24,  p.  825. 

2  Operat.  Surg.  Malig.  Disease. 

3  Deut.  nied.  Wochens.,  1886.  vol.  xii.  p.  157. 

17 


374  OPERATIVE  SURGERY. 

being  taken  to  avoid  injury  if  possible  to  the  facial  nerve, 
parotid  glaud,  and  external  carotid  artery.  The  ascending 
ramus  is  then  divided  horizontally  just  above  the  angle, 
and  partially  or  entirely  excised  after  severing  the  tendon 
of  the  temporal  muscle. 

After  drawing  aside  the  body  of  the  jaw,  together  with 
the  masseter,  internal  pterygoid,  digastric,  and  stylo-hyoid 
muscles,  the  region  of  the  tonsil  is  exposed.  The  lateral 
wall  of  the  pharynx  is  then  incised  and  access  thus  ob- 
tained to  the  palate,  base  of  the  tongue,  and  posterior 
pharyngeal  wall  as  far  up  as  the  naso-pharynx.  If  the 
digastric  muscle  and  hypoglossal  nerve  are  divided  the 
entrance  of  the  larynx  can  be  reached.  The  disease  is  re- 
moved with  the  knife  or  scissors,  the  mucous  membrane 
drawn  together,  and  the  wouud  closed  and  drained. 

Cheever's  Method.  An  oblique  incision  is  made  from  the 
lobule  of  the  ear  downward  along  the  anterior  border  of 
the  sterno-mastoid  muscle  to  the  hyoid  bone  or  below  it. 
A  second  is  carried  forward  from  this  along  the  lower 
border  of  the  body  of  the  inferior  maxilla.  The  tissues 
are  divided  layer  by  layer,  and  the  vessels  including  the 
external  jugular  secured.  Enlarged  lymphatic  glands  are 
removed  as  they  are  encountered.  The  branches  of  the 
facial  nerve  are  recognized  and  drawn  to  one  side.  The 
hypoglossal  nerve  lies  behind  and  in  the  lower  end  of  the 
incision,  and  is  drawn  outward  and  backward  with  the 
great  vessels.     The  glosso-pharyngeal  nerve  lies  anteriorly. 

The  fascia  investing  the  posterior  part  of  the  submaxil- 
lary gland  is  slit  up,  and  the  facial  artery  and  vein  tied. 
The  digastric  and  stylo-hyoid  muscles  are  divided,  the  sub- 
maxillary gland  drawn  forward  and  .the  parotid  up,  and 
the  walls  of  the  pharynx  thus  exposed. 

The  tonsil  and  the  surrounding  mucous  membrane  are 
then  removed.  Bird1  dispensed  with  the  incision  along 
the  lower  border  of  the  jaw,  but  slit  the  check  from  the 
angle  of  the  mouth  to  the  angle  of  the  jaw  and  removed 
the  tonsil,  using  one  finger  in  the  mouth  for  a  guide. 

1  Clin.  Soc.  Trans.,  vol.  xvi.  p. '.». 


SPECIAL  OPERATIONS.  375 


CESOPHAGOTOMY. 

The  oesophagus  begins  in  front  of  the  sixth  cervical  ver- 
tebra in  the  median  line,  or  just  behind  the  cricoid  cartilage  ; 
at  first  it  inclines  slightly  toward  the  left,  then  returns  to 
the  median  line  as  it  passes  behind  the  sternum,  inclines  to 
the  right  at  the  arch  of  the  aorta,  and  again  to  the  left  as 
it  approaches  the  diaphragm.  The  left  recurrent  laryngeal 
nerve  lies  between  its  cervical  portion  and  the  trachea,  the 
right  recurrent  nerve  lies  upon  its  outer  side.  It  is  covered 
anteriorly  by  the  trachea  and  left  lobe  of  the  thyroid  gland, 
and  crossed  by  the  left  inferior  thyroid  artery  and  vein. 
The  guide  to  it  is  the  trachea. 

Internal  (Esophagotomy.  Dr.  Sands  employed  an  in- 
strument constructed  on  the  principle  of  the  Otis  urethra- 
tome.  It  consisted  of  a  long  shank  carrying  a  bulb  with 
a  sheathed  knife  which  could  be  made  to  project  not  more 
than  an  eighth  of  an  inch  from  the  surface  of  the  envelop- 
ing bulb  by  turning  a  screw  in  the  handle.  Other  surgeons 
have  used  similar  instruments,  but  on  account  of  the  dan- 
ger of  perforating  the  oesophagus  operations  performed  by 
the  knife  from  the  interior  of  the  organ  have  been  prac- 
tically abandoned  in  favor  of  Abbe's  "string  saw"  method,1 
which  is  one  of  combined  dilatation  and  division. 

It  is  used  for  cicatricial  strictures  which  are  undilatable 
and  generally  impermeable  to  any  instrument  passed  from 
above,  but  which  reason  and  experience  have  shown  may 
be  passed  from  below,  as  in  the  latter  situation  the  tube  is 
contracted  aud  funnel-shaped,  while  above  it  is  dilated  and 
pouched. 

Gastrostomy  is  first  performed,  the  opening  into  the 
stomach  being  made  large  enough  to  admit  two  fingers  with 
the  exploring  instrument  to  the  cardiac  orifice  of  the  stomach . 
Into  the  latter  a  bougie  carrying  a  long  silk  cord  is  passed 
and  brought  out  at  the  mouth ;  the  other  end  of  the  cord 
remains  in  the  abdominal  wound.  Then  the  stricture  is 
made  tense  by  engaging  in  it  a  conical  bougie  as  large  as 
it  will  hold,  and  the  string,  held  well  back  in  the  pharynx 

1  New  York  Medical  Record,  February  25,  1893. 


376  OPERATIVE  SURGERY. 

and  stomach,  is  drawn  tight  and  sawed  up  and  down  a  few 
times.  After  this  bougies  are  passed  up  to  the  largest  size 
or  till  firm  resistance  is  encountered.  In  Abbe's  first  case 
external  cesophagotomy  was  performed,  and  after  division 
aud  dilatation  of  the  stricture  as  above  described  a  rubber 
tube  was  drawn  up  from  the  stomach  and  wedged  into  the 
contraction  for  twenty-four  hours,  thus  maintaining  the  dila- 
tation. 

When  there  is  no  further  trouble  in  the  passage  of  bou- 
gies from  above,  the  gastrostomy  wound  is  closed,  but  in- 
struments must  subsequently  be  introduced  through  the 
stricture  at  regular  intervals  till  the  danger  of  recontrac- 
tion  is  over.1 

External  (Esophagolomy.  The  operation  of  external 
cesophagotomy  may  be  required  for  the  relief  of  stricture, 
or  the  removal  of  a  foreign  body.  In  the  former  case,  it 
may  be  performed  above  or  at  the  level  of  the  stricture 
for  the  purpose  of  dividing  or  dilating  it,  or  below  the 
stricture  so  as  to  allow  the  introduction  of  food  into  the 
stomach.  The  left  side  of  the  oesophagus  is  more  accessi- 
ble in  the  neck  than  the  right,  and  the  incision  may  be 
made  in  the  median  line  or  parallel  to  the  inner  border 
of  the  sterno-cleido-mastoid  muscle.  As  the  walls  of  the 
oesophagus  are  flaccid,  a  guide  should  be  used  if  it  is  pos- 
sible to  introduce  one.  The  best  one  is  the  instrument 
known   as  Vacca-Berlinghieri's  sound  (Fig.   206).     It  is 

Fig.  '206. 


Vacca-Berlinghieri's  esophageal  sound. 

a  hollow  metallic  instrument,  curved  at  one  end  like  a 
urethral  sound,  but  to  a  less  degree,  with  a  long  opening 
in  the  concavity  or  on  the  left  side,  extending  not  quite  to 

1  A  resum6  of  this  operation  with  a  report  of  cases  and  description  of  the  vari- 
ous expedients  which  may  be  necessary  will  be  found  in  the  Annals  of  Surgery, 
March,  1895,  p.  253.    Dr.  Woolsey. 


SPECIAL  OPERATIONS.  377 

the  end.  Within  the  sound  is  an  elastic  staff,  the  side  of 
which  can  be  made  to  project  through  the  opening  and  dis- 
tend the  oesophagus,  its  point  being  engaged  in  the  cul-de- 
sac  at  the  extremity  of  the  sound.  In  some  cases  the 
foreign  body  cau  be  used  as  a  guide. 

Lateral  Incision.  Dorsal  decubitus,  head  extended,  face 
turned  slightly  to  the  right.  The  surgeon,  standing  at  the 
patient's  left,  makes  an  incision  through  the  skin,  subcu- 
taneous cellular  tissue,  and  the  platysma  a  little  on  the 
inner  side  of  the  inner  border  of  the  sterno-cleido-mastoid 
from  a  point  one  inch  above  the  sternum  to  the  level  of  the 
upper  border  of  the  thyroid  cartilage.  If  the  external  or 
anterior  jugular  is  encountered,  it  must  be  drawn  aside  or 
divided  between  two  ligatures.  The  fascia  is  then  divided, 
the  omo-hyoid  muscle  drawn  aside,  and  then  the  side  of  the 
thyroid  gland  followed  downward.  The  sterno-cleido-mas- 
toid and  the  great  vessels  are  drawn  outward  with  a  blunt 
hook,  the  trachea  and  thyroid  gland  to  the  right,  and  then 
the  surgeon,  working  with  his  fingers  or  blunt  instruments, 
separates  the  tissues  at  the  bottom  of  the  wound  and  ex- 
poses the  oesophagus,  which  can  be  recognized  by  its  flat- 
tened appearance  and  muscular  wall.  If  more  room  is 
needed,  the  sternal  head  of  the  sterno-cleido-mastoid  must 
be  divided.  Vacca's  sound  is  then  introduced  through  the 
mouth,  its  elastic  staff  projected  through  the  lateral  open- 
ing so  as  to  distend  the  oesophagus,  and  recognized  by  the 
ringer  at  the  bottom  of  the  wound  ;  or  an  ordinary  oesopha- 
geal bougie  is  used.  The  surgeon,  having  satisfied  himself 
that  the  recurrent  laryngeal  nerve  and  inferior  thyroid  artery 
are  out  of  the  way,  punctures  the  oesophagus  by  picking  it 
up  with  two  hooks  or  toothed  forceps  and  cutting  between 
them,  and  enlarges  the  opening  with  scissors  or  a  blunt- 
pointed  bistoury. 

At  the  close  of  the  operation  the  wound  in  the  oesopha- 
gus is  closed  with  catgut,  that  in  the  overlying  parts  being 
left  open  and  packed ;  the  patient  is  fed  by  the  rectum  or 
with  the  stomach  tube  for  several  days.  If  a  permanent 
fistula  is  desired  (below  a  malignant  contraction,  for  in- 
stance) the  margins  of  the  cutaneous  and  oesophageal  wounds 
are  united  with  sutures. 


378 


OPERATIVE  SURGERY. 


THE    OPERATIONS    ON    THE    THYROID    GLAND. 


Anatomy.  Normally  the  isthmus  is  about  half  an  inch 
long  and  covers  the  second  aud  third  tracheal  rings,  while 
the  lateral  lobes  extend  upward  and  backward  to  the  lower 
end  of  the  pharynx,  lying  on  each  side  of  the  larynx,  and 
downward,  in  contact  with  the  upper  end  of  the  oesophagus. 


Fig.  207. 


b  _ 


1 

11 

/       N$ 

a.  Chin.  b.  Sterno-mastoid.  c.  Omohyoid,  d.  Sternohyoid,  c.  Sterno-thy- 
roid.  /.  Vena  jugularis  ext.  g,  Vena  jugularis  obliqua.  //,.  Vena  jugnlaris 
ant.  i.  Vena  jugularis  inf.  commuuicans.  j.  Vena  jugularis  sup.  communi- 
cans.  1,  2,  3.  Double  ligatures  applied  to  the  above-mentioned  veins  in  the  line 
of  the  incision.    Kociier. 

The  thyroid  is  enveloped  by  the  fascia  of  the  neck  and  pos- 
sesses a  capsule  enclosing  the  gland  tissue  proper.  When 
enlarged  the  organ  is  covered  with  a  plexus  of  veins ;  the 
most  constant  and  importaut  of  these  are  represented  dia- 
gramatically  in  Figs.  207  and  208  and  need  no  further  ex- 


SPECIAL  OPERATIONS. 


379 


plauation.  The  gland  is  overlapped  by  the  sterno-mastoid 
and  has  resting  on  its  surface  the  sterno-hyoid,  omo-hyoid, 
and  sterno-thyroid  muscles  in  this  order  from  before  back- 
ward.   One  or  more  accessory  thyroids  may  be  found  above 


Fig.  208. 


a.  Sup.  thyroid  artery,  b.  Sup.  thyroid  veiD.  c.  Cartoid  artery,  d.  Internal 
jugular  vein.  e.  Accessory  sup.  thyroid  vein.  /.  Sup.  communicating  thyroid 
vein.  g.  Inf.  communicating  thyroid  vein.  h.  Accessory  inferior  thyroid  vein. 
i.  Inferior  thyroid  vein.  k.  Thyroidea  ima  veins.  I.  Left  innominate  vein. 
The  numerals  indicate  the  points  where  the  above-mentioned  veins  are  ligated. 


or  below  the  lateral  lobes,  and  it  should  be  noted  that  the 
latter  may,  when  enlarged,  extend  downward  behind  the 
sternum.  The  lateral  lobes  overlap  the  great  vessels  of  the 
neck  with  their  accompanying  nerves,  and  are  in  contact 
at  their  lower  posterior  portions  with  the  inferior  thyroid 
artery,  the  recurrent  laryngeal  nerve,  and  middle  cervical 
ganglion  of  the  sympathetic.  The  artery  passes  horizontally 
inward  from  the  inner  border  of  the  scalenus  anticus 
muscle   about    half  an  inch   below   the    carotid    tubercle. 


380  OPERATIVE  SURGERY. 

then  forward  on  the  oesophagus  and  trachea,  and  divides 
into  an  ascending  and  descending  branch.  At  its  point 
of  bifurcation  it  is  crossed  (in  front  or  behind)  by  the 
recurrent  laryngeal  nerve,  and  at  the  inner  border  of  the 
scalenus  anticus  the  middle  cervical  ganglion  lies  directly 
upon  it.  Great  care  is  necessary  in  securing  the  artery 
not  to  injure  these  structures;  paralysis  of  one  recurrent 
nerve  produces  paralysis  of  the  corresponding  vocal  cord, 
of  both  nerves,  severe  dyspnoea,  which  may  end  fatally  if 
not  relieved  by  tracheotomy  ;  injury  to  the  sympathetic  at 
this  point  destroys  the  three  cardiac  branches  which  are 
given  off  here  or  just  below.  The  operations  which  are 
considered  justifiable  are  removal  of  a,  portion  of  the  gland, 
enucleation  of  the  same,  and  ligation  of  the  afferent  arteries, 
the  latter  being  applicable  to  rapidly  growing,  vascular 
(not  fibrous  or  cystic)  goitres  in  young  subjects. 

Ligation  of  the  Arteries.  On  account  of  the  danger  of 
a  general  atrophy  only  those  vessels  in  immediate  connec- 
tion with  the  enlarged  part  should  be  secured,  the  superior 
and  inferior  thyroid  arteries  of  one  side,  for  example.  Then 
if  this  fail  the  others,  starting  with  the  nearest,  may  be  suc- 
cessfully tied.  The  superior  arteries  are  exposed  and 
ligated  as  described  on  page  39,  and  the  inferior  preferably 
by  Drobeck's  method  (p.  40),  especially  if  the  gland  is  much 
hypertrophied. 

Enucleation  of  a  Portion  of  the  Gland.  Some  cases  of 
sharply  defined  tumor  of  the  thyroid,  such  as  cystic  goitre, 
need  only  a  longitudinal  incision  over  the  most  prominent 
part  of  the  growth  with  division  of  the  tissues  layer  by 
layer,  and  ligation  of  the  vessels  encountered  till  the  gland 
is  reached.  The  capsule  and  layer  of  gland  tissue  (some- 
times no  thicker  than  a  sheet  of  paper)  overlying  the  tumor 
is  then  divided  and  the  latter  shelled  out. 

Removal  of  a  Portion  of  the  Thyroid  Gland  (Kocher). 
The  incision  extends  vertically  in  the  median  line  from  the 
sternal  notch  to  the  upper  limit  of  the  tumor.  From  this 
point  it  runs  obliquely  toward  the  angle  of  the  jaw  on  the 
sidefrom  which  the  affected  half  of  the  gland  is  to  be  removed 


SPECIAL  OPERATIONS.  381 

(Fig.  207).  If  the  entire  gland  is  to  be  removed,  a  pro- 
cedure which  must  be  seldom  justifiable,  the  oblique  incision 
is  made  on  both  sides,  thus  giving  the  skin-cut  the  form  of 
a  Y.  The  integument,  fascia,  and  platysma  are  divided  and 
the  flaps  turned  back.  The  sterno-hyoid,  sterno-thyroid, 
and  omo-hyoid  muscles,  which  may  be  much  thinned  and 
stretched  out  over  the  surface  of  the  tumor,  will  have  to  be 
cut.  If  adherent  to  its  surface  they  should  be  lifted  and 
pushed  aside  with  blunt-pointed  scissors  or  a  periosteal  eleva- 
tor. A  plexus  of  large  thin-walled  veins,  which  tear  very 
easily,  will  be  found  lying  close  over  the  surface  of  the  en- 
larged gland,  and  should  be  divided  separately  between 
double  ligatures.  The  anterior  surface  of  the  growth  is  thus 
cleared  and  the  lateral  aspect  approached.  The  sterno- 
mastoid  muscle  is  retracted  and  the  common  carotid  artery 
and  internal  jugular  vein  are  carefully  freed  with  a  blunt 
instrument.  The  superior  thyroid  artery  is  secured  at  the 
upper  extremity  of  the  tumor  and,  together  with  the  accom- 
panying veins,  divided  between  a  double  ligature.  It 
is  generally  recommended  to  cut  the  branches  of  the  inferior 
thyroid  artery  close  to  the  tumor  and  secure  each  as  it  is 
divided,  as  in  this  way  there  is  less  danger  of  injuring  the 
recurrent  laryngeal  nerve  which  is  in  close  relationship  with 
it  on  both  sides.  Furthermore,  on  the  left  side  the  main 
portion  of  the  artery  lies  in  contact  with  the  oesophagus  and 
the  thoracic  duct,  which  is  at  first  posterior  to  the  artery, 
arches  over  it  to  reach  the  left  subclavian  vein,  or  the 
trunk  of  the  inferior  thyroid  artery  may  be  tied,  preferably 
by  Drobeck's  method,  as  described  on  page  40. 

The  dissection  is  continued  close  to  the  capsule,  which 
must  nowhere  be  opened  ;  every  vessel,  as  it  is  encountered, 
is  tied  and  cut  separately  after  careful  inspection,  and  the 
lateral  surface  of  the  tumor  cleared.  Its  margin  is  lifted 
up,  starting  at  one  side  above  and  working  downward  and 
inward ;  the  trachea  and  oesophagus  are  separated  with 
special  regard  for  the  recurrent  laryngeal  nerve  which  lies 
in  the  groove  between  these  structures.  Thus  the  dissection 
is  carried  from  the  side  as  far  as  the  middle  line  posteriorly. 
The  gland  is  then  drawn  forward  and  upward.  The  vessels 
entering  it  from  below  are  secured  and  divided  and  the 
gland  removed. 

17* 


382  OPERATIVE  SURGERY. 

Removal  of  the  Isthmus.1  A  median  longitudinal  incision 
is  employed.  It  exteuds  from  the  upper  to  the  lower  bor- 
der of  the  enlarged  isthmus  aud  involves  the  integument  and 
superficial  fascia.  The  anterior  jugular  vein,  if  encountered, 
is  secured  and  cut  between  a  double  ligature.  The  interval 
between  the  sterno-hyoid  aud  sterno-thyroid  muscles  is 
opened  up  aud  the  muscles  drawn  aside.  The  isthmus  is 
exposed  after  carefully  ligating  separately  each  one  of  the 
enlarged  veins  which  may  be  encountered  in  front  of  it.  It 
is  then  freed  on  its  upper  and  lower  border  and  posteriorly 
with  a  bluut  instrument.  The  capsule  itself  must  not  be 
opened  and  every  vessel  should  be  tied  as  it  is  encountered. 

An  aneurism-needle  threaded  with  a  double  ligature  is 
then  made  to  perforate  the  isthmus  on  each  side  from  behind 
forward  at  its  junction  with  the  lateral  lobes,  and  at  these 
points  it  is  tied  off  like  an  ovariau  pedicle  and  the  isthmus 
cut  close  to  'the  ligatures  and  removed. 

The  parenchymatous  injection  of  tincture  of  iodine,  of 
iodine  and  absolute  alcohol,  or  of  a  mixture  of  iodoform, 
ether,  and  olive  oil  has  been  practically  abandoned  as  too 
dangerous.  With  every  antiseptic  precaution  a  hypodermic 
needle  was  plunged  into  the  enlarged  gland,  and  if  blood 
or  fluid  could  be  withdrawn  it  showed  that  a  vessel  or  cyst 
had  been  entered  and  negatived  the  injection.  When,  after 
reintroduction,  the  point  of  the  needle  was  thus  demon- 
strated to  occupy  only  gland  tissue,  from  half  a  gramme  to 
a  gramme  of  tincture  of  iodine  was  slowly  injected,  the  sur- 
geon desisting  immediately  on  the  appearance  of  syncope  or 
dyspnoea. 


CHAPTER  V. 

OPERATIONS    UPON   THE   THORAX. 

AMPUTATION    OF   THE    BREAST. 

The  patient  is  planed  upon  her  back,  inclined  somewhat 
toward  the  opposite  side,  and  the  arm  abducted  so  as  to 
make  the  skin  and  pectoral  muscle  tense.     Two  curved  in- 

Jonea :  Lancet,  1875,  vol.  i.  p.  120. 


SPECIAL  OPERATIONS.  383 

cisions  are  made,  one  on  each  side  of  the  nipple,  enclosing 
an  elliptical  strip  of  skin  of  greater  or  less  breadth  accord- 
ing to  circumstances,  the  long  axis  of  which  is  directed 
toward  the  axilla ;  that  is,  upward  and  backward.  The 
upper  and  lower  skin  flaps  are  then  dissected  01T  the  an- 
terior surface  of  the  gland,  its  upper  border  turned,  expos- 
ing the  pectoral  muscle,  and  the  loose  cellular  tissue  be- 
tween it  and  the  muscle  rapidly  divided  with  a  few  strokes 
of  the  knife,  beginning  at  the  upper  border  of  the  inner 
angle,  while  the  gland  is  drawn  away  from  the  chest  wall, 
and  the  removal  completed  along  the  lower  incision,  or  at 
the  axillary  angle  of  the  wound. 

Bleeding  during  the  operation  must  be  controlled  by 
clamps  upon  the  bleeding  points,  and  the  vessels  secured 
afterward  with  ligatures  or  by  torsion.  The  incision  is 
then  prolonged  just  posterior  to  the  anterior  fold  of  the 
axilla,  up  to  the  arm.  The  axillary  vein  is  exposed  at  the 
outer  end  of  the  incision,  where  it  is  most  superficial  and  is 
kept  constantly  in  sight  as  the  dissection  progresses.  The 
axillary  glands  whether  perceptibly  enlarged  or  not,  together 
with  the  surrounding  fat  and  connective  tissue,  are  removed 
en  masse. 

Halsted1  advises  that  the  fascia  covering  the  pectoralis 
major  under  the  breast  be  alivays  dissected  otf  from  the  sur- 
face of  the  muscle,  and  in  many  cases  that  the  latter  together 
with  the  pectoralis  minor  be  removed  entirely. 


PARACENTESIS    OF    THE   THORAX. 

Each  of  the  lower  posterior  intercostal  arteries  enters  its 
corresponding  intercostal  space  near  the  spinal  column,  and 
passes  obliquely  from  below  upward  across  the  space  to 
shelter  itself  in  a  groove  on  the  inner  side  of  the  lower 
border  of  the  upper  rib.  It  occupies  this  groove  until  it 
reaches  the  anterior  third  of  the  space,  when  it  leaves  it  to 
anastomose  with  the  branches  of  the  anterior  intercostal 
artery  coming  from  the  internal  mammary.  At  this  point, 
however,  it  is  so  small  that  its  division  is  not  of  much  con- 

1  Aunals  of  Surgery,  1894 


384  OPERATIVE  SURGERY. 

sequence.  The  only  part  of  its  course  where  its  injury  is 
to  be  feared  is  in  the  posterior  third  of  the  intercostal  space 
before  it  has  passed  behind  the  lip  of  the  rib.  Consequently, 
if  an  opening  is  to  be  made  into  the  pleural  cavity,  either 
with  a  knife  or  trocar,  a  point  in  the  middle  third  of  one  of 
the  intercostal  spaces  should  be  selected,  preferably  the 
seventh,  certainly  not  higher  than  the  sixth,  nor  lower  than 
the  eighth  on  the  right  side,  the  ninth  on  the  left. 

After  determining  the  position  of  the  intercostal  space, 
often  a  matter  of  considerable  difficulty  in  consequence  of 
the  infiltration  of  the  parts,  make  an  incision  parallel  to  it, 
one  or  one  and  one-half  inches  in  length.  Divide  the  tissues 
layer  by  layer,  until  the  rib  can  be  distinctly  felt  with  the 
finger  introduced  into  the  wound.  Place  the  end  of  the 
finger  upon  the  upper  border  of  the  lower  rib,  and,  keep- 
ing the  knife  close  to  the  border,  divide  the  muscles  and 
pleura. 

If  a  trocar  or  the  aspirator  is  used,  it  must  be  thrust  in 
with  a  sharp  push  so  as  certainly  to  penetrate  the  pleura, 
which  is  often  thick  and  tough.  The  outer  eud  of  the 
cauula  is  then  connected  with  a  Dieulafoy  or  Potaiu  as- 
pirator by  means  of  a  rubber  tube  and  the  effusion  drawn 
off.  A  better  method  is  to  make  use  of  the  principle  of 
the  siphon.  After  filling  the  canula  and  tube,  previously 
rendered  aseptic,  with  sterilized  water,  the  end  of  the  tube 
is  occluded  and  the  canula  thrust  into  the  pleural  cavity. 
The  tube  is  then  conducted  beneath  the  surface  of  a  1  :  60 
solution  of  carbolic  acid  below  the  level  of  the  patient's 
bed,  and  released,  thus  siphoning  off  the  liquid  in  the 
chest. 

PARACENTESIS   OF   THE   PERICARDIUM. 

Normally  the  pericardium  is  in  contact  with  the  chest 
wall  only  in  the  median  line  under  the  sternum  ;  but  when 
its  sac  is  distended  with  liquid  the  area  of  contact  becomes 
much  larger,  especially  by  extension  downward  and  to  the 
left.  The  heart  is  at  the  same  time  pressed  upward  and 
backward.  The  limits  of  the  pericardium  can  be  ascer- 
tained with  great  accuracy  by  percussion  and  auscultation, 
and  this  should  always  be  done  before  puncturing.     At  the 


SPECIAL  OPERATIONS.  385 

point  selected  for  puncture  the  pulsations  of  the  heart  should 
be  imperceptible,  or  at  least  very  faint,  and  it  should  be 
absolutely  flat  on  percussion.  It  should  also  be  remem- 
bered that  the  internal  mammary  artery  ruus  parallel  to 
the  side  of  the  sternum,  and  a  finger's  breadth  from  it. 

If  the  knife  is  used  the  tissues  must  be  divided  layer  by 
layer,  aud  the  finger  should  always  be  introduced  into  the 
wound  before  the  pericardium  itself  is  incised,  to  make  sure 
that  the  heart  is  not  in  contact  with  it. 


CHAPTER  VI. 

OPERATIONS     UPON    THE     ABDOMINAL    WALL,     STOMACH, 
AND    INTESTINES. 

PARACENTESIS    OF   THE   ABDOMEN. 

In  order  to  avoid  injury  to  the  different  viscera,  and  es- 
pecially to  the  internal  epigastric  artery,  which  runs  from 
the  middle  of  Poupart's  ligament  toward  the  umbilicus,  the 
puncture  should  be  made  either  in  the  median  line  midway 
between  the  umbilicus  and  the  symphysis  pubis,  or  midway 
between  the  umbilicus  and  the  anterior  superior  spine  of 
the  ilium.  The  iustrumeut  used  is  a  trocar  aud  canula  or 
the  needle  of  an  aspirator.  The  depth  to  which  it  shall  be 
allowed  to  penetrate  is  regulated  by  the  finger  placed  upon 
its  side,  and  it  should  be  plunged  in  sharply,  without  a  pre- 
liminary incision,  at  the  selected  point,  which  should  be 
absolutely  flat  upon  percussion.  As  there  is  a  possibility  of 
syncope  occurring  during  the  operation,  in  consequence  of 
the  withdrawal  of  pressure,  it  is  prudent  first  to  pass  a 
broad,  many-tailed  flannel  bandage  about  the  abdomen, 
crossing  its  ends  behind,  so  that  an  assistant  standing  at 
each  side  can  draw  upon  them  and  tighten  the  bandage  as 
the  liquid  escapes.  It  is  usually  sufficient,  however,  to  have 
an  assistant  make  steady  pressure  with  one  hand  on  each 
side  of  the  abdomen.  During  the  operation  the  patient 
should  be  seated  or  inclined  toward  one  side. 


386  OPERATIVE  SURGERY. 

Should  hemorrhage  ensue,  the  attempt  must  first  be  made 
to  control  it  by  the  pressure  of  the  canula  or  of  a  larger 
gum  catheter  introduced  through  the  puncture.  This  fail- 
ing, the  entire  thickness  of  the  abdominal  wall  must  be 
pinched  up  and  compressed,  or,  in  extreme  cases,  the 
wound  must  be  enlarged  and  the  vessel  tied. 

When  it  is  necessary  to  practise  paracentesis  upon  a 
pregnant  woman,  Ollivier  recommends  the  selection  of  the 
neighborhood  of  the  umbilicus  for  the  puncture ;  Scarpa 
preferred  the  left  hypochondrium,  Velpeau  the  left  flank. 


LAPAROTOMY. 

If  time  permits  preparatory  treatment  with  baths  and 
laxatives  is  continued  for  several  days,  and  in  a  female 
pelvic  case  the  vagiua  is  rendered  as  aseptic  as  possible  by 
numerous  1  :  2000  bichloride  douches.  An  aperient  is  given 
the  evening  before  and  an  euema  in  the  morning  of  the 
operation  ;  the  patient  passes  water  or  is  catheterized  imme- 
diately before  being  placed  on  the  table.  The  preparation 
of  the  skin  surface,  the  surgeon,  the  attendants,  instru- 
ments, and  accessories  has  been  already  given.  Sterilized 
sponges,  round  and  flat,  and  a  few  on  clamps  or  handles, 
and  pads  of  gauze  should  be  at  hand,  and  two  sterilized 
basins  of  warm  boiled  water,  one  to  contain  the  clean 
sponges,  and  the  other,  which  will  need  frequent  changing, 
to  rinse  the  soiled  sponges. 

All  parts  of  the  patient,  except  the  abdominal  surface, 
all  the  tables  for  instruments,  sponges  aud  dressings,  and 
everything  not  previously  sterilized,  which  may  be  touched 
by  any  person  or  thing  concerned  in  the  wound,  are  covered 
with  sterilized  towels,  dry  or  wet  in  a  1  :  1000  bichloride 
of  mercury  solution.  The  numbers  of  clamps,  sponges, 
and  pads  are  written  down  immediately  before  the  opera- 
tion and  verified  at  the  close. 

The  incision  may  be  made  in  almost  any  part  of  the  ab- 
dominal wall,  but  is  most  often  median  and  should  divide; 
the  tissues  layer  by  layer.  The  linea  alba  is  indistinct  below 
the  umbilicus,  and  if  the  incision  is  median  one  or  other 
rectus  sheath  will  generally  be  opened.     It  will  then  be 


SPECIAL  OPERATIONS.  387 

found  convenient  to  immediately  unite  by  a  catgut  suture 
the  anteror  and  posterior  layers  of  the  opened  sheath,  and 
the  linea  alba  can  thus  be  more  quickly  reformed  at  the 
close  of  the  operation.  The  preperitoneal  fat  is  recognized 
and  all  bleeding  stopped.  The  peritoneum  is  then  nicked 
and  the  opening  eularged  with  blunt-pointed  scissors  to  the 
length  of  the  abdominal  wound,  which  must  be  made  large 
enough  to  permit  easy  recognition  of  everything  as  it  is  en- 
countered. 

The  position  of  the  bladder  must  be  remembered.  The 
field  of  operation  is  then  fenced  in  like  a  well  with  sterilized 
gauze  pads  or  flat  sponges,  and  the  viscera  outside  of  the 
spot  in  question  entirely  hidden  in  the  rest  of  the  unopened 
abdominal  cavity. 

Pelvic  operations  are  much  facilitated  by  the  Trendelen- 
burg position — the  hips  elevated  above  the  shoulders,  thus 
causing  the  viscera  to  gravitate  out  of  the  way.  Each 
vessel  is  secured  separately,  if  possible,  before  division  ; 
there  must  be  no  cutting  in  the  dark  and  no  ligation  of 
large  masses  of  tissue  en  masse.  In  general  catgut  is  pref- 
erable to  silk  for  almost  all  pedicles  or  vessels. 

At  the  close  of  an  aseptic  laparatomy  the  perfectly  dry 
and  clean  wound  is  inspected  for  a  few  moments  to  be  sure 
that  there  is  no  more  bleeding ;  the  clamps,  sponges,  and 
pads  are  removed  and  counted,  and  the  viscera  are  then 
allowed  to  resume  their  normal  positions.  A  flat  sponge 
or  pad  is  placed  over  the  viscera  iu  the  abdominal  wound 
to  protect  them  and  to  absorb  such  blood  as  may  flow  from 
the  needle  punctures,  and  over  this  the  wound  is  closed  by 
various  methods. 

Silk,  silver  wire,  or  silkworm-gut  can  be  passed  through 
the  whole  thickness  of  the  abdominal  wall  and  peritoneum, 
from  half  an  inch  to  an  inch  from  the  margin  of  the  wound, 
and  about  the  same  distance  apart ;  the  amount  of  tension 
necessary  in  tying  them  will  vary  with  the  thickness  of  the 
abdominal  wall,  its  laxity,  or  distention.  Before  the  last 
one  or  two  are  tied  the  protecting  sponge  is  withdrawn,  or 
the  peritoneum  may  be  first  sutured  over  the  sponge  by  the 
continuous  or  interrupted  catgut  suture  and  the  sponge 
withdrawn  before  it  is  entirely  closed,  then  sutures  of  silk, 
silver  wire,  or  silkworm-gut  are  passed  as  before,  but  only. 


388  OPERATIVE  SURGERY. 

through  the  parts  in  front  of  the  peritoneum,  or  after  clos- 
ing the  peritoneum  and  removing  the  sponge  the  overlying 
parts  can  be  sutured  with  catgut,  layer  by  layer.  Schede1 
recommends  buried  sutures  of  silver  wire  for  all  the  layers 
except  the  peritoneum  and  skin.  In  a  continuously  asep- 
tic wound  the  sutures  should  not  be  removed  for  at  least 
seven  days,  and  then  with  every  antiseptic  precaution,  es- 
pecially if  they  include  the  peritoneum. 

The  sutured  wound  may  be  covered  with  a  strip  of  steril- 
ized rubber  tissue.  Iodoform  gauze  is  next  applied,  and 
over  this  layers  of  plain,  sterilized,  or  bichloride  gauze. 

This  is  held  in  place  with  a  couple  of  transverse  strips  of 
adhesive  plaster  and  covered  with  a  layer  of  sterilized  ab- 
sorbent gauze,  and  the  dressing  completed  by  a  broad  ab- 
dominal binder  or  a  broad  roller  bandage  applied  circularly 
around  the  body  and  each  thigh  in  the  form  of  a  spica  to 
prevent  slipping. 

The  sponges  contaminated  in  the  course  of  a  laparotomy, 
where  any  form  of  sepsis  or  noxious  element  is  present, 
should  be  kept  apart  from  the  others  as  far  as  possible, 
and  only  used  in  the  contaminated  area,  which  latter 
must  be  kept  separated  by  sterilized  sponges  or  pads,  with 
the  utmost  care,  from  the  rest  of  the  abdominal  cavity. 
The  towels  in  the  neighborhood  of  the  wound  are  changed 
or  covered  with  clean  ones  as  fast  as  they  become  soiled, 
and  the  wall  of  pads  or  sponges  surrounding  the  operation 
area  must  be  replaced  by  fresh  ones  when  they  become 
saturated  with  the  noxious  materials,  and  without  disturb- 
ing the  position  of  the  protected  viscera. 

The  wound  at  the  finish  is  made  as  clean  and  dry  as  pos- 
sible. Wherever  peritoneum  has  been  divided  or  stripped 
up  it  should  be  replaced  and  secured  with  fine  catgut  su- 
tures. There  may  remain  a  large  denuded  area  liable  to 
infection  or  studded  with  fine  bleeding  points,  as,  for  in- 
stance, after  dissection  of  an  adherent  tumor.  This  can  be 
conveniently  treated  with  a  large  square  of  iodoform  or 
sterilized  gauze,  the  centre  of  which  is  tucked  down  into 
contact  with  this  area,  and  the  edges  brought  out  of  the 
abdominal   wound.     Other  strips  of  sterilized  gauze  are 

1  ('entralblatt  flir  Chirurgie,  1893. 


SPECIAL  OPERATIONS.  389 

packed  into  this  as  into  a  bag.  If  pus  has  been  present  one 
or  more  sterilized  drainage  tubes  of  rubber  or  glass  with 
lateral  perforations  must  be  run  down  from  the  surface  to 
the  bottom  of  the  infected  region.  Sometimes  a  strip  of 
gauze  is  packed  inside  of  the  tubes  to  aid  the  escape  of 
fluid  on  the  principle  of  capillarity.  And  this  strip  is  fre- 
quently changed  with  every  antiseptic  precaution. 

In  female  pelvic  cases  it  may  be  desirable  to  pass  a  tube 
through  a  counter-opening  in  the  vault  of  the  vagina. 
Hence  the  necessity  of  the  preliminary  cleansing  of  the 
vagina  in  every  case  where  there  is  even  a  possibility  of 
pelvic  complications.  The  vagina  is  afterward  packed  with 
sterilized  or  iodoform  gauze,  the  vulva  covered  with  an  anti- 
septic dressing,  and  the  patient  catheterized  for  several 
days  subsequently.  After  inserting  the  tubes,  and  with  as 
little  displacement  of  the  protected  viscera  as  possible,  the 
sponges  or  pads  are  removed  and  counted  and  their  places 
supplied  by  a  light  packing  of  strips  of  iodoform  or  simple 
sterilized  gauze,  the  ends  of  which  protrude  through  the 
incision.  Before  packing  the  wound  it  may  be  advisable 
to  flush  out  the  infected  region  with  warm  boiled  water  or 
sterilized  salt  solution,  and  sometimes  a  large  part  of  or 
the  whole  peritoneal  cavity  is  thus  treated  and  counter- 
openings  for  drainage,  with  packing,  are  made. 

At  the  close  of  the  operation  the  peritoneum  is  first  su- 
tured over  a  sponge  or  pad  down  to  the  point  of  exit  of 
the  tubes  and  packing,  and  the  sponge  then  removed.  The 
overlying  parts  are  drawn  together  to  a  corresponding  ex- 
tent with  silk,  silkworm-gut,  or  silver  wire  passed  through 
everything  in  front  of  the  peritoneum,  and  a  dressing  which 
covered  the  ends  of  any  tubes  is  then  applied,  as  in  an 
aseptic  case. 


OPERATIONS    ON    THE    INTESTINES. 

Anatomy.  (Fig.  209.)  The  parts  of  the  intestines  which 
have  a  mesentery  are  completely  covered  by  peritoneum 
except  along  a  narrow  interval  where  the  lamina?  of  the  mes- 
entery diverge  to  encircle  the  bowel  (Fig.  209,  2).  Thus 
the  outer  wall  of  the  gut,  along  the  line  where  the  mesentery. 


390 


OPERATIVE  SURGERY. 


meets  it,  is  formed  by  a  strip  of  the  muscular  coat  about  five- 
sixteenths  of  an  iuch  wide  (Fig.  209,  3),  and  this  is  apt  to  be 
FlG  209  the  weak  point  in  a  row  of  sutures 

l;  involving  this  portion  of  the  cir- 

i,j 1      cumference   of  the    bowel.       The 

arteries  in  the  mesentery  form 
freely  anastomosing  loops  from 
which,  close  to  the  intestiue,  arise 
straight  vessels  with  little  or  no 
intercommunication,  and  having  a 
circular  and  fairly  well-defined  dis- 
tribution, so  that,  while  a  portion 
of  the  mesentery  at  a  distance 
from  the  intestine  may  be  de- 
stroyed with  comparative  impu- 
nity, an  injury  to  the  small- 
est part  in  immediate  proximity 
to  the  gut  involves  a  probability 
of  sloughing  of  a  corresponding 
extent  of  intestine. 

An  anatomical  knowledge  of  the 
mesentery  is  of  value  in  a  search 
for  the  upper  or  lower  end  of  the 
small  intestine.  The  parietal  at- 
tachment of  the  mesentery  ex- 
tends from  the  left  side  of  the 
second  lumbar  vertebra  down- 
ward to  the  right  iliac  fossa,  and,  if  the  finger  trace  the 
left  layer  of  the  mesentery  of  a  loop  of  intestine  back 
toward  the  spine,  it  passes  oft'  toward  the  left  side  of  the 
abdomen,  and  the  right  layer  will  lead  to  the  right  side  of 
the  abdomen.  This  will  show  which  end  is  the  upper  or 
lower  in  any  particular  loop.  Also  the  upper  end  of  the 
small  intestine  has  a  greater  diameter,  is  thicker  walled 
(valvnlse  conniventcs),  and  more  vascular  than  the  lower 
end.  The  coats  of  the  intestine  from  without  inward  are  : 
(1)  the  peritoneal,  (2)  the  longitudinal,  (3)  circular  muscu- 
lar, (4)  the  submucosa,  a  tough  fibrous  membrane,  (5)  the 
muscularis  mucosae,  and  (6)  the  mucosa,  the  latter  making 
up  about  two-thirds  of  the  thickness  of  the  wall. 

Unless  the  suture  includes  a  shred  of  the  submucosa  it 


Section  of  small  intestine  and 
mesentery. 

1.  Mesentery. 

2.  Triangular  space  between 
diverging  layers  of  the  mesen- 
tery. 

'6.  Its  base  resting  on  m,  the 
muscular  coat  of  the  gut. 
P.  Peritoneum. 
m,.m.  Mucous  membrane 


SPECIAL  OPERATIONS.  391 

is  very  apt  to  tear  oat.  This  coat  is  recognizable  by  the 
increased  resistance  which  it  offers  to  the  passage  of  the 
needle  after  the  peritoneal  and  muscular  layers  have  been 
traversed.1  The  colon  and  sigmoid  flexure  are  recogniza- 
ble by  their  corrugations,  their  more  or  less  fixed  posi- 
tions, the  appendices  epiploicse,  which  are  most  numerous 
in  the  transverse  colon,  and  by  the  longitudinal  bands  of 
muscular  fibres.  The  anterior  band  is  the  largest  and  most 
prominent,  and  lies  in  front  of  the  caecum,  colon,  and  sig- 
moid flexure.  In  the  trausverse  colon  it  corresponds  to 
the  attachment  of  the  great  omentum,  and  in  the  ascending 
colon  and  csecum  it  is  the  unfailing  guide  to  the  appendix 
vermiformis,  from  the  attachment  of  which  to  the  csecum 
the  anterior,  inner,  and  posterior  longitudinal  bands  all 
start.  The  appendix  lies  about  opposite  a  point  indicated 
on  the  abdomen  by  the  centre  of  the  line  passing  from  the 
right  anterior  superior  spine  of  the  ilium  to  the  umbilicus. 
It  may  or  may  not  have  a  mesentery  and  commonly  lies 
behind  the  lower  end  of  the  ileum,  and  often  in  close  rela- 
tion with  the  iliac  vessels  and  ureter,  and  is  not  infre- 
quently found  in  the  pelvis. 

To  be  successful  the  closure  of  an  intestinal  wound  must 
be  water-tight,  and  no  stitch  may  perforate  all  the  coats ; 
there  must  be  no  subsequent  giving  way  of  any  part  of  the 
wound,  either  from  slipping  of  a  suture  or  ulceration  or 
sloughing  at  the  site  of  its  insertion,  and  the  lumen  of  the 
bowel  must  not  be  unduly  narrowed.  A  round  sewing 
needle  and  black  silk  are  generally  used. 

The  continuous  suture  is  applied  like  the  ordinary 
continuous  suture  already  described,  and  is  carried  a  short 
distance  beyond  the  extremities  of  a  longitudinal  wound. 
The  needle  penetrates  the  peritoneal  and  muscular  coats, 
of  the  intestine,  catching  up  a  few  fibres  of  the  sub- 
mucosa,  but  nowhere  entering  the  mucosa.  The  stitches 
are  placed  at  intervals  of  about  a  quarter  of  an  inch  close 
to  the  margins  of  the  wound,  which  are  turned  in  to  bring 
the  peritoueal  surfaces  in  apposition. 

The  right-angled  continuous  suture  (Fig.  210)  only  differs 
from    this  last  in  having  the  buried  portions  parallel  to 

1  Halsted  :  American  Journal  Medical  Sciences,  1887,  p.  436. 


392 


OPERATIVE  SURGERY. 


the  line  of  the  wound  and  the  exposed  portions  at  right 
angles  to  it. 

The  continuous  suture  cau  be  rapidly  applied,  and  is 
useful  for  reinforcing  weak  points  in  an  interrupted  suture 


Fig.  210. 


Right-angled  continuous  intestinal  suture.    (Greig  Smith.) 

line,  but  it  is  inapplicable  for  closing  a  complete  trans- 
verse division  of  the  bowel.  All  parts  of  the  continuous 
suture  may  not  be  drawn  equally  tight,  and  the  contraction 
of  the  gut  tends  to  loosen  it  and  allow  the  wound  to  gape. 
The  interrupted  suture  of  Lembert  is  the  most  approved 
and  generally  used  intestinal  suture.  The  needle  pene- 
trates a  fold  of  the  peritoneal,  muscular,  aud  a  few  shreds 
of  the  submucous  coat  of  the  gut  on  opposite  sides  of  the 
wound,  the  margins  of  which  are  inverted  and  the  perito- 
neum brought  together.  The  sutures  should  be  placed 
about  an  eighth  of  an  inch  from  the  margin  of  the  wound 
and  about  the  same  distance  apart,  and  each  should  grasp 


SPECIAL  OPERATIONS. 


393 


a  fold  of  the  intestine  about  one-tenth  or  one- twelfth  of  an 
inch  wide.     None  must  touch  the  mucosa. 


Fig.  211. 


Diagram  representing  the  methods  of  inserting  the  Czerny-Lembert  sutures. 
The  Lemhert  suture  is  below,  the  Czerny  at  the  cut  edge. 

Czerny's  method  consisted  of  an  interrupted  line  of  sutures 
passing  through  all  coats  of  the  intestine  and  tied  inside. 

Fig.  212. 


Halsted  quilt  suture  for  the  intestines. 


A  second  row  of  Lembert  sutures  is  then  added  to  bring 
the  peritoneal  surfaces  on  each  side  of  the  wound  in  conr 


394  OPERATIVE  SURGERY. 

tact  over  the  first  row  of  sutures.     Czerny's  suture  is  now 
generally  passed  through  all  coats  except  the  outer  one. 

Ualsted's  quilt  sutures1  will  bear  a  considerable  strain. 
It  is  a  modification  of  Lembert's  method.  The  needle 
peuetrates  the  superficial  coats  of  the  gut  twice  on  each 
side  of  the  wound  and  is  then  knotted. 


CIRCULAR  ENTERORRAPHY. 

This  is  the  usual  term  for  designating  an  end-to-end 
suture  of  the  intestine  from  which  a  segment  has  been  re- 
moved. 

Operation.  The  loop  of  intestine  is  carefully  drawn  out 
of  the  abdomen  and  surrounded  by  warm  pads  or  sponges 
while  the  opening  into  the  peritoneal  cavity  is  protected  by 
a  gauze  or  sponge  packing.  The  feces  are  squeezed  out  of 
the  loop,  and  about  an  inch  above  and  below  the  limits  of 
the  segment  of  gut  to  be  removed  the  intestine  is  con- 
stricted tightly  enough  to  close  its  lumen,  either  by  the 
fingers  of  an  assistant  or  by  any  one  of  the  specially  designed 
clamps.  A  convenient  method  is  to  tie  lightly  around  the 
bowel  at  these  points  a  strip  of  iodoform  gauze,  which  is 
passed  through  a  small  hole  made  in  the  mesentery  by  a 
blunt  instrument  at  a  little  distance  from  the  gut.  After 
thoroughly  protecting  the  exposed  peritoneal  surface,  at  the 
spot  selected  on  the  lower  side  of  the  disease,  the  intestine 
is  divided  squarely  across  and  its  interior  immediately  irri- 
gated with  warm  boiled  water.  With  a  clean  pair  of  scissors, 
the  mesentery  of  the  diseased  part  is  cut  as  close  to  the  gut 
as  possible  up  to  the  intended  upper  point  of  the  intestinal 
division. 

If  there  is  much  distention,  the  iodoform-gauze  band 
above  should  not  be  tied  till  after  the  freed  portion  of 
intestine  has  been  conducted  off  to  one  side  and  its  con- 
tents ;il lowed  to  escape,  aided  by  kneading  the  abdomen. 
While  the  gut  is  being  divided  the  lumen  above  should  be 
occluded  by  the  pressure  of  an  assistant's  fingers;  the  in- 

|  American  Journal  Medical  Sciences,  October,  1887. 


SPECIAL  OPERATIONS. 


395 


testine  is  then  constricted  about  an  inch  above  the  upper 
line  of  division  as  already  described,  and  cut  squarely 
across,  leaving  no  protrusion  beyond  the  mesenteric  attach- 
ment, and  the  interior  below  the  constricting  gauze  band 
immediately  irrigated  as  before. 

The  divided  meseutery  should  not  be  removed  in  the 
form  of  a  triangle  with  its  base  corresponding  to  the  excised 
gut.      Bleeding  is  checked  by  separate  ligation  with  fine 

Fig.  213. 


Circular  enterorraphy. 


catgut  of  each  vessel.  Meanwhile  every  portion  of  peri- 
toneum is  scrupulously  protected  from  infectious  matter,  and 
before  the  next  step  instruments  which  have  touched  infec- 
tious matter  or  the  interior  of  the  intestine  are  discarded 
and  the  hands  carefully  washed. 

The  ends  of  the  gut  are  then  brought  into  apposition  and 
the  mucous  membrane  united  evenly  all  around  by  a  con- 
tinuous catgut  or  silk  suture.  The  mesenteric  border  of  the 


396  OPERATIVE  SURGERY. 

gut  is  drawn  together  by  a  Lembert  silk  suture  and 
then  the  opposite  free  border.  By  gentle  traction  on  the 
ends  of  these  sutures  (Fig.  213)  the  gut  is  flattened  out 
and  on  the  line  thus  indicated  the  necessary  number  of 
Lembert  sutures  are  added,  but  not  tied  till  the  last  is  in 
place.  The  peritoneal  surfaces  must  be  very  carefully 
brought  into  contact  at  the  mesenteric  attachment  of  the 
bowel  to  avoid  leakage  into  the  areolar  tissue  between  the 
diverging  layers  of  the  mesentery ;  but  weak  points  must 
not  be  so  reinforced  by  continuous  or  interrupted  sutures 
that  the  lumen  of  the  intestine  becomes  unduly  narrowed. 
The  fold  of  detached  mesentery  is  drawn  together  at  its 
cut  edge  with  catgut,  and  if  long  enough  it  is  sometimes  ad- 
vised to  suture  its  peritoneal  surface  over  the  line  of  intes- 
tinal union  as  far  as  it  will  reach  without  tension. 

Senn  sutures  the  great  omentum  over  the  outer  row  of 
Lembert  sutures  and  has  thus  covered  a  circular  enteror- 
raphy  with  a  detached  omental  graft  an  inch  wide  and 
long  enough  to  encircle  the  bowel.1  The  parts  are  again 
irrigated  with  warm  boiled  water,  the  intestinal  clamps  or 
gauze  bands  are  removed  together  with  the  protective 
sponge  packing,  and  after  returning  the  gut  to  the  abdomen 
the  parietal  wound  is  closed  in  the  usual  way. 


INTESTINAL   ANASTOMOSIS. 

This  is  the  formation  of  a  lateral  communication  between 
the  lumina  of  two  different  portions  of  the  gut.  Owing  to 
the  contraction  in  the  calibre  of  the  intestine  which  follows 
circular  enterorraphy,  this  operation  of  anastomosis  is  fre- 
quently adopted  in  its  place,  though  it  was  originally  intro- 
duced as  a  palliative  means  of  relieving  an  irremovable 
obstruction  of  the  bowel,  by  uniting  the  parts  above  and 
below  the  obstruction. 

Operation.  Above  and  below  the  obstruction  healthy 
portions  of  the  gut  are  selected  which  can  be  brought  into 
apposition  without  tension,  along  several  inches  of  surface. 

1  Trans.  Int.  Med.  Cong  ,  !itli  session,  Washington,  1887,  vol.  i.  p.  435. 


SPECIAL  OPERATIONS.  397 

The  rest  of  the  peritoneal  cavity  is  walled  off  with  sponges, 
and  if  possible  the  selected  loops  of  intestine  are  drawn 
out  of  the  abdomen  and  surrounded  by  warm  cloths. 
About  one-quarter  of  an  iuch  to  the  under  side  of  the 
centre  of  the  convex  free  border  as  the  intestine  lies  ex- 
posed, the  apposing  loops  are  united  for  about  five  inches 
by  a  continuous  silk  suture  through  the  peritoneal  coats 
alone.  In  front  of  this,  nearer  to  the  free  border,  is  placed 
a  row  of  Lembert  sutures  for  the  same  distance.  About 
an  inch  above  and  below  this  suture  line,  on  each  loop,  an 
iodoform-gauze  band  is  passed  through  the  mesentery, 
where  it  is  free  from  vessels,  at  a  little  distance  from  the  in- 
testine, and  tied  around  the  gut  just  tightly  enough  to  pre- 
vent the  entrance  of  fecal  matter.  Each  loop  is  then 
opened  along  its  convex  free  border  for  nearly  the  same 
distance  (about  four  inches)  parallel  to  and  immediately  in 
front  of  the  second  row  of  sutures  already  in  place.  The 
openings  should  terminate  opposite  each  other  about  half  an 
inch  short  of  the  end  of  the  suture  line.  The  interior  of 
each  isolated  loop  is  immediately  irrigated  clean  with  warm 
boiled  water,  while  the  exposed  peritoneal  surface  is  pro- 
tected as  far  as  possible. 

Soiled  towels  or  protecting  sponges  are  then  replaced  by 
clean  ones,  anything  which  has  touched  the  interior  of  the 
intestine  or  its  contents  is  discarded  and  the  hands  carefully 
washed.  After  this  the  extruded  mucous  membrane  of  the 
opposite  intestinal  loops  is  united  by  a  continuous  catgut 
or  silk  suture.  The  exposed  parts  are  again  irrigated  and 
the  protectives  and  instruments  changed. 

A  row  of  Lembert  silk  sutures  is  then  placed  close  to  and 
in  front  of  the  already  united  parts  as  they  lie  in  view, 
starting  and  terminating  at  the  ends  of  the  row  of  posterior 
Lembert  sutures.  This  can  be  strengthened  by  a  continu- 
ation of  the  first  posterior  continuous  silk  suture  through 
the  peritoneal  coat.  The  four  gauze  constricting  bauds  are 
then  removed  from  the  intestine,  the  protective  sponges 
taken  out  of  the  abdomen,  the  bowel  returned,  and  the 
parietal  wound  closed  in  the  usual  way. 

In  cases  of  euterectomy  the  segment  of  gut  to  be  re- 
moved is  excised  as  described  iu  circular  enterorraphy. 
The  open  ends  of  the  intestine  are  then  turned  in  to  bring 

18 


398 


OPERATIVE  SURGERY. 


peritoneal  surfaces  into  contact,  and  closed  by  a  continuous 
silk  suture  carried  back  and  forth  once  or  twice  and  in  no 
spot  entering  the  mucosa.  The  constricting  gauze  bands 
are  removed  from  the  intestine  and  the  anastomosis  pro- 
ceeded with. 

Senn1  reinvented  and  greatly  improved  the  forgotten 
method  of  uniting  different  portions  of  the  gut  laterally  by 
means  of  perforated  absorbable  plates  which  bring  into 
contact  broad  areas  of  peritoneum  around  a  central  opening. 

Fig.  214. 


Senn's  plates,  a,  a,  lateral  or  fixation  suture  ;  b,  b,  end  or  apposition  suture. 
Thread  passed  through  2  is  brought  out  through  1,  and  that  through  4  out  through 
3.    (Treves.) 

Two  contiguous  loops  of  intestine  are  opened  to  the  same 
extent  longitudinally,  on  the  side  opposite  the  attachment 
of  the  mesentery,  and  sufficiently  to  admit  the  plates  edge- 
wise. After  introduction  the  plates  are  rotated  enough  to 
make  their  perforations  correspond  to  the  openings  made  in 
the  intestine.  About  a  quarter  of  an  inch  from  the  mar- 
gins of  the  openings  on  each  side,  the  wall  of  the  intestine 


1  Trans.  Int.  Med.  Cong.,  9th  session,  Washington,  1887,  vol.  i.  p.  435. 


SPECIAL  OPERATIONS. 


399 


is  perforated  by  the  two  lateral  sutures  which  are  armed 
with  needles.  The  other  two  sutures  are  tied  across  the  ex- 
tremities of  the  openings  without  perforating  the  intestinal 
wall. 


Fig.  215. 


Intestinal  anastomosis,  with  Senn's  plates,    a,  a,  lateral  or  fixation  sutures  ; 
b,  b,  end  or  apposition  sutures  ;  c,  c,  posterior  sutures.    (Senn.) 


The  sutures  serve  the  double  purpose  of  holding  the 
parts  in  apposition  and  keeping  the  openings  patent. 

After  the  parts  are  brought  together  union  is  further  se- 
cured by  a  continuous  or  interrupted  suture  through  the  peri- 


400 


OPERATIVE  SUBGEBY. 


toneal  coat  around  the  margins  of  the  plates.  The  plates, 
which  Senn  made  of  decalcified  bone,  are  supposed  to  be- 
come absorbed  or  disintegrated  between  the  third  and  tenth 
days. 

This  method  has  been  largely  abandoned  in  this  country 
on  account  of  the  later  contraction  of  the  fistula. 

The  Murphy  "  button  "  has  lately  attained  great  popu- 
larity as  a  means  of  uniting  differeut  portions  of  the  intes- 
tine, although  its  value  for  this  purpose  has  been  contested 
by  many  surgeons.  A  description  of  the  device  and  its 
application  will  be  found  in  the  paragraphs  on  cholecysten- 
terostomy.  Quite  recently  a  satisfactory  substitute  has 
been  found  in  a  piece  of  raw  potato  perforated  and  fashioned 
into  similar  shape. 

Various  methods  have  been  devised  for  uniting  portions 
of  gut  of  unequal  diameter,  but  they  have  now  been  gen- 
erally superseded  by  closing  the  transversely  divided  ends 
aud  performing  lateral  anastomosis. 

Ileo-sigmoidestomy.  Cases  of  irremovable  obstruction  in 
the  colon  have  been  successfully  treated  by  an  anastomosis 

Fig.  216. 


Intcriok  of  Smaller 
Secmentof  Gut 


Miiunsell's  method  ;  first  two  sutures  brought  out  through  the  incisiou  in  the 
lower  segment. 


between  the  lower  end  of  the  ileum  and  the  sigmoid  flexure 
after  the  ileum  has  been  divided  and  separated  from  the 


SPECIAL  OPERATIONS.  401 

colon   at  the  ileo-csecal  valve.     The   abdominal    incision 
is  made  in  the  median  line  below  the  umbilicus. 

Union  of  Divided  Intestine  by  Intussusception  (Maunsell).1 
The  disease  is  excised  by  transverse  division  of  the  gut  as 
described  in  circular  enterorrhaphy.  The  cut  ends  of  the 
intestine  are  united  by  one  suture  through  the  entire  wall 
at  the  point  of  the  mesenteric  attachment  and  by  another 
at  the  point  directly  opposite.  The  portion  of  intestine 
which  lies  on  the  lower  or  rectal  side  of  the  line  of  division, 
starting  about  an  inch  from  this  line,  is  opened  longitudinally 
on  its  convex  free  border  for  about  two  inches.  Through  this 
incision  the  long  ends  of  the  two  sutures  are  passed  and  the 
gut  invaginated  and  its  partially  united  cut  ends  drawn 

Fig.  217. 


Maunsell's  method ;  protruding  ends  ready  for  suture. 

out  through  the  opening.  (Figs.  216  and  217.)  Sutures 
of  fine  silk  are  then  passed  through  both  sides  of  the  ex 
posed  invaginated  gut  at  the  same  time  close  to  its  cut 
edge,  hooked  up  from  the  centre,  cut  apart  and  tied.  The 
intestine  is  then  withdrawn  from  the  opening  and  the 
longitudinal  slit  closed  by  Lembert  sutures. 

1  Amer.  Journ.  Med.  Sci.,  1892,  vol.  103,  p.  245. 


402  OPERATIVE  SURGERY. 


ENTEROTOMY. 

Instead  of  excision  of  a  portion  of  the  gut  with  imme- 
diate restoration  of  its  continuity  by  circular  enterorraphy 
or  lateral  anastomosis,  circumstances  such  as  an  uncertain 
amount  of  gangrene,  the  bad  condition  of  the  patient,  etc., 
may  require  that  the  bowel  he  simply  freed  from  its  con- 
striction and  the  damaged  part  left  outside  the  abdomen  till 
the  slough  separates.  It  is  fastened  to  the  margins  of  the 
abdominal  wound  by  a  couple  of  sutures  through  the 
peritoneal  and  muscular  coats,  and  protected  by  a  dry  anti- 
septic dressing.  In  course  of  time  it  is  treated  by  the 
method  described  for  the  closure  of  an  artificial  anus. 
Other  cases  may  need  to  be  treated  as  described  for  enter- 
otomy  or  colotomy,  with  immediate  opening  of  the  gut  close 
to  or  at  the  seat  of  disease. 


RIGHT  INGUINAL  ENTEROTOMY  (NBLATON's  OPERATION). 

As  long  ago  as  1819,  it  was  proposed  to  establish  an 
artificial  anus  in  the  ileum  in  case  the  intestinal  obstruction 
could  not  be  found  or  removed  by  laparotomy  ;  but  Nelaton 
was  the  first  (1840)  to  substitute  this  for  the  other  opera- 
tion, giving  up  the  search  after  the  obstruction  entirely. 
His  theory  was  that  many  obstructions  would  relieve  them- 
selves in  time,  if  a  temporary  outlet  should  be  furnished  to 
the  accumulation  above;  in  some  cases,  on  the  other  hand, 
where  the  obstruction  is  permanent,  an  artificial  anus  in  the 
ileum  meets  the  "  vital  indication"  perfectly — for  example, 
when  the  obstruction  is  in  the  lower  portion  of  the  small 
intestine;  while  in  others,  again,  where  the  occlusion  occurs 
below  the  ileo-csecal  valve,  and  the  relief  afforded  would, 
consequently,  be  imperfect,  the  obstruction  is  usually  due 
to  malignant  disease,  which  in  itself  would  soon  destroy 
life,  and  against  which  neither  laparotomy  nor  any  other 
operation  would  avail. 

It  is  also  essential  to  the  proper  nourishment  of  the  patient 
that  the  greater  part  of  the  small  intestine  should  remain 
serviceable ;  that  is,  that  the  opening  should  be  made  in  the 


SPECIAL  OPERATIONS.  403 

lower  part  of  the  ileum.  Of  course,  this  cannot  be  accom- 
plished when  the  obstruction  is  situated  high  up,  but,  in 
other  cases,  Nelaton  fouud  that  the  intestinal  loops  nearest 
the  obstruction  always  occupied  the  right  iliac  fossa,  and 
he,  therefore,  cut  through  the  abdominal  wall  just  above 
the  outer  half  of  Poupart's  ligament  on  the  right  side,  and 
opened  the  first  loop  that  presented  in  the  incision.  The 
portion  of  the  intestine  below  an  obstruction  is  always  empty 
and  shrunken,  and  does  not  come  into  contact  with  the  ante- 
rior abdominal  wall,  so  that  there  is  no  danger  of  making 
the  opening  in  it  by  mistake.  It  occasionally  happens  when 
the  obstruction  is  situated  in  the  colon  that  the  distended 
caecum  fortunately  presents  in  the  incision,  and  the  artificial 
anus  is  established  below  the  ileo-csecal  valve. 

Operation.  Make  an  incision  parallel  to  and  about  an 
inch  above  Poupart's  ligament,  beginning  at  the  anterior 
superior  spine  of  the  ilium  and  ending  opposite  the  internal 
abdominal  ring. 

Divide  the  tissues  layer  by  layer,  pick  up  and  nick  the 
peritoneum  and  open  it  for  about  one  and  a  half  inches. 
The  first  distended  intestinal  loop  which  presents  is  drawn 
out  till  its  free  border  is  on  a  level  with  the  skin,  and  re- 
tained by  two  silk  or  silkworm-gut  sutures,  which,  at  the 
same  time,  draw  together  the  extremities  of  the  abdominal 
wound.  Each  suture  passes  through  all  the  parietal  tissues 
and  the  peritoneal  and  muscular  coats  of  the  intestine.  The 
skin  and  bowel  are  closely  united  all  around  by  interrupted 
sutures,  none  of  which  must  enter  the  lumen  of  the  gut. 

The  suture  line  is  covered  by  a  strand  of  iodoform  gauze 
pasted  down  with  flexible  collodion,  and  the  centre  of  the 
protruding  intestinal  wall  opened  in  its  long  axis  for  about 
half  an  inch. 

The  parietal  peritoneum  can  be  drawn  out  and  stitched 
to  the  skin  before  the  bowel  is  sutured  in  place,  thus  bring- 
ing into  contact  a  larger  surface  of  parietal  and  visceral 
peritoneum. 

COLOTOMY. 

Left  Inguinal  Qolotomy.  Make  an  incision  between  two 
and  three  inches  long,  according  to  the  thickness  of  the 


404  OPERATIVE  SURGERY. 

abdominal  wall,  parallel  to  and  about  an  inch  above  Pou- 
part's  ligament,  with  its  centre  at  the  level  of  the  anterior 
superior  spine  of  the  ilium,  or  a  little  lower.  The  tissues 
are  divided  layer  by  layer,  the  peritoneum  opened,  and  the 
skin  and  parietal  peritoneum  united  by  a  few  sutures,  not 
including  the  muscles.  The  sigmoid  flexure,  which  is  recog- 
nized by  its  anterior  longitudinal  band,  its  convoluted  sur- 
face, or  appendices  epiploicse,  is  drawn  into  the  opening  and 
retained  by  a  couple  of  silk  or  silkworm-gut  sutures  passed 
about  two  inches  apart  through  both  lips  of  the  wound  at 
its  extremities  and  the  longitudinal  band  of  the  colon.  The 
gut  is  then  closely  united  to  the  margins  of  the  wound  by 
fine  silk  sutures  passing  through  the  already  joined  skin 
and  peritoneum  and  the  outer  coats  of  the  intestine.  No 
suture  must  penetrate  to  its  interior.  The  amount  of  the 
circumference  of  the  gut  to  lie  external  to  the  sutures  is 
about  half  an  inch  when  the  operation  is  for  the  temporary 
relief  of  obstruction.  For  a  permanent  artificial  anus  two- 
thirds  of  the  circumference  of  the  bowel  should  lie  anterior 
to  the  suture  line.  The  centre  of  the  exposed  intestinal 
wall  is  then  opened  longitudinally  with  a  knife  or  thermo- 
cautery for  about  half  an  inch  and  drainage  tubes  inserted. 

Before  opening  the  bowel  the  suture  line  can  be  covered 
with  a  strip  of  iodoform  gauze  pasted  over  with  flexible 
collodion.  If  there  is  no  hurry  the  opening  can  be  deferred 
for  five  or  six  days  till  adhesions  have  shut  oif  the  general 
peritoneal  cavity. 

Some  surgeons  prefer  not  to  unite  the  skin  and  parietal 
peritoneum,  but  to  suture  the  outer  coats  of  the  intestine 
to  the  skin  alone.  The  gut  adhering  to  all  parts  between 
the  skin  and  parietal  peritoneum  is  thought  less  liable  to 
retract  than  if  adherent  only  to  the  intervening  parietal 
peritoneum  with  its  movable  subserous  areolar  tissue. 

Maydl1  hangs  the  intestine  on  a  sterilized  rod  passed 
through  the  mesentery  close  to  the  bowel  and  laid  on  the 
skin  transversely  to  the  wound.  The  apposing  walls  of 
this  loop  are  united  by  a  few  interrupted  sutures  through 
the  peritoneal  coats  and  the  rest  of  the  walls  left  to  adhere 
to  the  abdominal  wound  ;  but  if  immediate  opening  is  in- 

>  Centralb.  f.  Chir.,  1888,  No.  24. 


SPECIAL  OPERATIONS.  405 

tended,  the  sutures  are  passed  through  the  skin  and  perito- 
neum around  the  margins  of  the  incision,  and  through  the 
serous  and  muscular  coats  of  the  gut,  completely  separating 
the  peritoneal  cavity.  The  exposed  wall  of  the  intestine 
is  opened  transversely  for  one-third  of  its  circumference, 
and  drainage  tubes  placed  within  it.  Two  or  three  weeks 
later  the  bowel  is  entirely  divided  on  this  line  and  the  cut 
edges  sutured  to  the  skin  for  a  permanent  artificial  anus. 

If  the  operation  is  merely  temporary  the  intestine  is 
opened  longitudinally,  and  when  adhesions  have  formed 
the  rod  is  withdrawn,  and  the  bowel  retracts  and  the  fistula 
sometimes  closes  spontaneously. 

Right  inguinal  colotomy  only  differs  from  the  last  opera- 
tion in  that  the  abdominal  incision  is  placed  on  the  right 
side  and  the  csecurn  is  opened  instead  of  the  sigmoid 
flexure. 

Median  colotomy,  by  fixing  the  ascending  or  descending 
colon  in  the  median  line  between  the  umbilicus  and  pubes, 
has  nothing  to  recommend  it  over  the  inguinal  method. 

Lumbar  Colotomy.  This  operation  was  first  suggested 
by  Callisen,1  in  1797,  as  a  substitute  for  Littre's  or  inguinal 
colotomy  with  a  view  to  avoiding  the  dangers  incidental  to 
au  incision  through  the  peritoneum.  He  proposed  to  open 
the  descending  colon  in  the  posterior  third  of  its  periph- 
ery, where  it  is  not  covered  by  peritoneum.  So  far  as 
known,  Amussat  was  the  first  to  perform  the  operation 
in  1839,  and  although  he  opened  the  ascending  colon,  and 
by  a  transverse  instead  of  a  vertical  incision,  the  opera- 
tion was  essentially  the  same  as  that  proposed  by  Callisen. 
All  that  portion  of  the  descending  colon  which  lies  above 
the  crest  of  the  ilium  is  usually  uncovered  by  peritoneum 
on  its  posterior  aspect,  and  although  the  actual  breadth 
of  the  uncovered  portion  varies  with  the  degree  of  dis- 
tention of  the  bowel,  it  usually  amounts  to  one-third  of 
the  entire  circumference,  and  is  bounded  on  each  side  by 

1  Erskine  Mason  :  Six  Cases  of  Lumbar  Colotomy,  Amer.  Journ.  of  Med.  Sciences, 
Oct.  1873. 

18* 


406  OPERATIVE  SURGERY. 

one  of  the  three  longitudinal  bundles  of  unstriped  muscle 
characteristic  of  the  colon.  In  position  it  corresponds 
nearly  to  the  outer  border  of  the  quadratus  lumborura, 
and  very  exactly  to  a  vertical  line  drawn  a  full  half  inch 
behind  the  centre  of  a  transverse  one,  uniting  the  anterior 
and  posterior  superior  spines  of  the  ilium  (Mason).  On 
the  right  side  (ascending  colon)  the  uncovered  portion  is 
more  often  smaller,  and  the  existence  of  an  actual  meso- 
colon, although  rare,  is  yet  more  frequent  than  upon  the 
left  side. 

Callisen  proposed  a  vertical  incision  a  little  external  to 
the  outer  border  of  the  erector  spinse ;  Amussat  made  a 
transverse  one  midway  between  the  last  rib  and  the  crest 
of  the  ilium,  while  Baudens  and  Bryant  used  an  oblique 
one  passing  downward  and  outward  at  an  angle  of  45°. 
The  latter  is  to  be  preferred,  because,  while  giving  sufficient 
room,  it  inflicts  less  injury  upon  the  vessels  and  nerves  of 
the  parts,  the  general  direction  of  which  is  the  same  as  that 
of  the  incision. 

The  operation  is  performed  as  follows  :  The  patient  is 
etherized,  and  placed  in  a  position  midway  between  the 
prone  and  right  lateral,  a  hard  cushion  being  placed  traus- 
versely  uuder  the  right  loin  to  keep  the  spine  straight  or 
slightly  curved  toward  the  left.  Mason1  says  the  operation 
has  been  performed  with  the  patient  seated  and  leaning 
forward  over  the  back  of  another  chair,  local  anaesthesia 
being  obtained  by  means  of  the  ether  spray.  The  anterior 
and  posterior  superior  spines  of  the  left  ilium  are  then 
recognized,  and  a  vertical  line  drawn  upward  from  a  point 
one-half  to  three-quarters  of  an  inch  behind  the  centre  of 
a  transverse  line  drawn  from  one  to  the  other.  This  verti- 
cal line  should  be  marked  with  iodine  or  nitrate  of  silver, 
in  order  to  serve  as  a  guide  during  the  operation 

If  the  occlusion  of  the  intestine  has  not  been  complete, 
and  there  is  reason  to  suppose  that  the  colon  will  be  found 
empty,  it  may  now  be  distended  by  injecting  air  or  water 
through  the  rectum.  Mason  prefers  air,  and  gives  good 
reasons  for  the  preference. 

A  transverse  or  an  oblique  incision  four  or  five  inches 

1  Loc.  cit. 


SPECIAL  OPERATIONS.  407 

long  is  then  made,  its  centre  lying  in  the  vertical  line 
above  mentioned  midway  between  the  last  rib  and  the 
ilium.  The  underlying  tissues  are  recognized  and  divided 
layer  by  layer,  until  the  fascia  transversalis  and  quadratus 
lumborum  are  reached.  The  former  is  next  carefully 
divided,  and,  if  the  adipose  tissue  covering  the  colon  does 
not  then  appear  in  the  wound,  the  latter  should  be  en- 
larged on  the  inner  side  by  dividing  the  outer  fibres  of 
the  quadratus.  The  intestine  must  always  be  sought  for 
in  the  angle  of  the  wound  nearest  the  spine,  and  when- 
ever it  is  desired  to  increase  its  exposed  area  this  must  be 
done  in  the  same  direction.  Bleeding  should  be  arrested 
as  it  occurs,  certainly  before  the  intestine  is  opened. 

The  colon  can  usually  be  recognized  by  its  distention 
and  greenish  hue,  and  possibly  by  one  of  its  longitudinal 
bands.  Additional  light  may  be  thrown  upon  the  correct- 
ness of  the  recognition  by  noticing  whether  the  supposed 
colon  corresponds  exactly  to  the  vertical  line  marked  upon 
the  skin,  and  whether  or  not  it  moves  up  aud  down  with 
the  acts  of  inspiration  and  expiration,  for  while  the  small 
intestine  has  this  motion  the  lumbar  colon  has  it  not. 

Two  stout  ligatures  are  next  passed  by  means  of  curved 
needles  through  the  presenting  portion  of  intestine  and 
used  to  draw  it  up  into  the  wound,  and  fasten  it  to  the 
skin  at  the  sides  of  the  incision.  The  wound  is  then  filled 
with  sponges  or  gauze,  and  the  bowel  opened  by  a  longi- 
tudinal or  crucial  incision.  As  soon  as  the  discharge  has 
ceased,  the  sponges  or  gauze  are  withdrawn,  the  parts 
cleaned,  the  extremities  of  the  tegumentary  wound  closed 
with  silver  sutures,  and  the  edges  of  the  opening  in  the  in- 
testine made  fast  to  the  skin  with  a  few  sutures  of  fine  silk. 


CLOSUEE   OF   AN   AETIFICIAL    ANUS   OE   FECAL   FISTXJEA. 

If  the  opening  in  the  gut  is  large,  the  remaining  part  of 
the  intestinal  wall  is  pressed  forward  into  it  and  forms  a 
sort  of  valve  or  spur,  which  prevents  more  or  less  com- 
pletely the  descending  current  of  feces  from  entering  the 
lower  segment  of  the  bowel. 

If  this  spur  were  absent  the  fistula  might  close  sponta- 


408  OPERATIVE  SURGERY. 

neously,  and  to  accomplish  its  removal  Dupuytren's  enter- 
otome  was  formerly  introduced  through  the  opening  and 
clamped  upon  the  spur,  which  was  thus  cut  through  by  four 
or  five  days  of  continued  pressure. 

Fig.  218. 


Dupuytren's  enterotome. 

Immediately  before  undertaking  any  operation  the 
lumen  of  the  gut  above  and  below  the  fistula  is  plugged 
by  a  sponge  tied  to  a  string  which  serves  to  withdraw  the 
sponge  when  all  is  ready  to  close  the  intestinal  opening. 
The  interior  of  the  gut  is  then  irrigated  clean  and  the  skin 
surrounding  the  fistula  thoroughly  scrubbed  and  washed 
with  bichloride  solution. 

In  most  cases  the  fistulous  tract  between  the  intestine 
and  skin  is  lined  with  mucous  membrane,  and  if  the  spur 
is  slight  or  absent,  an  attempt  to  close  the  fistula  should 
first  be  made  by  separating  the  mucous  membrane  at  its 
junction  with  the  skin,  and  after  removing  the  sponge 
plugs,  inverting  it,  and  uniting  the  freshened  surfaces  with 
fine  catgut.  Over  this  the  pared  edges  of  the  abdominal 
opening  are  sutured  with  fine  silk,  aided,  if  necessary  at 
the  sides,  by  liberating  incisions  through  the  skin  and 
fascia. 

If  this  fails  or  a  more  elaborate  operation  seems  necessary, 
an  incision  two  or  three  inches  long  is  carried  across  the 
fistula  in  any  suitable  direction,  and  layer  by  layer  down  to 
the  peritoneum.  This  is  opened  at  one  extremity  of  the 
incision  ami  a  finger  inserted  into  the  abdomen  to  deter- 
mine the  limit  of  the  adhesions  ;  and  as  soon  as  possible 


SPECIAL  OPERATIONS.  409 

the  peritoneal  cavity  is  walled  off  by  sponges  packed  in 
around  the  open  intestine,  which  has  been  previously 
plugged  above  and  below  as  already  described.  Cutting 
on  the  finger  as  a  guide,  the  gut  is  separated  from  its 
parietal  attachment  around  the  fistula,  and  if  possible 
drawn  out  of  the  abdomen  and  constricted  above  and  below 
the  plugs  by  gauze  bands  passed  through  the  mesentery. 

The  sponge  plugs  are  withdrawn,  the  interior  of  the  gut 
irrigated,  and,  if  the  openiug  is  small,  its  edges  are  fresh- 
ened and  inverted,  and  the  peritoneal  coat  drawn  together 
over  it  with  Lembert  sutures.  The  constricting  bands  are 
removed  and  the  gut  returned  to  the  abdomen,  which  is 
closed  tight  in  the  usual  way.  If  the  opening  is  extensive, 
the  damaged  segment  of  the  gut  is  excised  and  circular 
enterorraphy  performed,  or  better  still,  after  excision,  lat- 
eral anastomosis. 

The  fistulous  tract  is  then  dissected  out  of  the  abdominal 
wall  and  the  wound  closed  tight. 

The  Operation  for  the  Removal  of  the  Vermiform  Ap- 
pendix. In  a  case  of  appendicitis  operated  on  in  the  period 
of  quiescence,  an  incision  three  or  four  inches  long  is  made 
at  the  outer  border  of  the  right  rectus  muscle,  with  its 
centre  about  on  the  line  joining  the  umbilicus  and  the  an- 
terior superior  spine  of  the  right  ilium.  The  lower  ex- 
tremity of  the  incision  should  not  reach  the  deep  epigastric 
artery,  the  course  of  which  is  indicated  by  a  line  drawn 
from  the  femoral  ring  to  the  umbilicus. 

The  tissues  are  divided  layer  by  layer,  all  bleeding 
stopped,  and  the  peritoneum  pinched  up  and  opened  the 
whole  length  of  the  incision.  Adhesions  are  separated  by 
the  finger-nail  or  blunt-pointed  scissors,  and  if  necessary 
divided  between  a  double  ligature.  The  anterior  longi- 
tudinal band  of  the  colon  is  traced  to  its  origin  at  the  root 
of  the  appendix.  After  walling  off  the  surrounding  peri- 
toneum with  a  sponge  packing,  the  appendix  is  isolated  and 
a  double  ligature  of  stout  catgut  passed  by  an  aneurism 
needle  through  its  mesentery  close  to  the  root  of  the  ap- 
pendix. The  needle  is  withdrawn,  the  loop  of  the  ligature 
cut,  and  on  one  side  the  mesentery,  which  usually  contains 
a  single  artery,  is  tied  off,  and  on  the  other  side  the  ap- 


410  OPERATIVE  SURGERY. 

pendix  is  Hgated  as  close  to  the  caecum  as  possible.  The 
mesentery  and  appendix  are  then  excised  close  to  the  distal 
side  of  the  ligatures.  The  csecal  stump  of  the  appendix  is 
held  isolated  and  in  view  till  thoroughly  cauterized  with  the 
Paquelin  or  pure  carbolic  acid,  but  in  using  the  latter  care 
must  be  taken  to  prevent  its  spreading  to  the  neighboring 
surface  of  the  caecum. 

The  sponge  protectives  are  then  removed,  the  parts 
allowed  to  assume  their  normal  position,  and  one  end  of  a 
strand  of  iodoform  gauze  is  placed  in  contact  with  the  cau- 
terized stump  and  the  other  end  brought  out  of  the  abdom- 
inal wound. 

The  peritoneum  and  overlying  parts  are  closed  tight  in 
the  usual  way  except  where  the  gauze  drain  emerges.  Here 
a  suture  of  silk  is  passed  through  the  entire  thickness  of 
the  abdominal  wall,  including  the  peritoneum,  and  left  un- 
tied till  the  drain  is  removed  forty-eight  hours  later.  This 
must  be  done  with  every  antiseptic  precaution,  and  only 
done  if  no  inflammatory  symptoms  exist.  The  dressings 
then  applied  are  left  undisturbed  about  ten  days. 

Dr.  31cBurney1  has  given  us  a  method  which,  while  more 
difficult  of  execution,  obviates  the  risk  of  hernia  :  An  inci- 
sion, oblique  downward  and  inward,  is  made  about  an  inch 
and  a  half  to  the  inner  side  of  the  anterior  superior  spine 
of  the  ilium.  The  aponeurosis  of  the  external  oblique  is 
split  in  the  direction  of  its  fibres,  the  sheath  of  the  inter- 
nal oblique  divided  transversely,  and  its  fibres  and  those  of 
the  transversalis  carefully  separated  without  cutting  from 
the  ilium  to  the  rectus.  The  fascia  and  peritoneum  are 
divided,  the  sides  of  the  opening  held  apart  with  broad 
retractors,  and  the  appendix  removed  as  above  described. 

Operation  during  the  Period  of  Inflammation.  If  a 
distinct  tumefaction  is  perceptible,  with  a  probability  of  the 
presence  of  pus,  the  incision  is  made  about  four  inches  long 
parallel  to  the  outer  border  of  the  right  rectus  over  the 
most  prominent  part  of  the  tumor,  or,  if  there  is  no  tume- 
faction,   over   the    most   tender   spot,  and    the   appendix 

1  Annals  of  Surgery,  1894. 


SPECIAL  OPERATIONS.  411 

removed  as  already  described.  If  the  peritoneum  is  reached 
without  a  previous  escape  of  pus  it  is  opened  at  an  angle 
of  the  incision,  preferably  the  upper,  and  a  finger  inserted 
to  determine  the  positiou  of  the  mass  and  the  limit  of  the 
adhesions.  Through  this  exploratory  opening  a  sponge 
packing  is  inserted  as  soon  as  possible,  and  the  inflamed 
area  walled  off  from  the  rest  of  the  abdominal  cavity. 

The  peritoneal  opening  is  then  enlarged  and  the  dissec- 
tion carried  into  the  densest  part  of  the  tumefaction.  Fresh 
adhesions  are  best  separated  by  tearing  with  the  finger-nail, 
but  the  possibility  of  lacerating  the  bowel  must  not  be 
forgotten,  and,  if  necessary,  the  blunt-pointed  scissors  and 
double  catgut  ligature  are  used  for  the  strongest  adhesions, 
especially  those  involving  omentum.  The  moment  pus 
appears  the  manipulations  are  suspended,  while  it  is  encour- 
aged to  flow  out  or  else  sponged  rapidly  away  without 
disturbing  the  relations  of  the  surrounding  parts. 

The  opening  in  the  abscess  cavity  is  cautiously  enlarged 
without  getting  beyond  the  adhesions  which  protect  the 
rest  of  the  peritoneal  cavity.  If  such  an  accident  does 
occur  a  clean  sponge  is  immediately  packed  into  the  rent 
and  the  dissection  continued  until  the  appendix  is  found. 
It  should  always  be  removed  to  prevent  subsequent  attacks, 
and  it  is  always  possible  to  find  it  by  following  the  auterior 
longitudinal  band  of  the  csecum.  It  is  excised  and  the 
stump  cauterized  in  the  manner  already  described. 

An  abscess  cavity  in  the  pelvis  may  sometimes  need  to 
be  drained  by  a  tube  passed  through  a  counter-opening  in 
the  rectum  and  a  cavity  in  the  loin  by  a  tube  passed  through 
the  back  just  above  the  iliac  crest. 

After  every  trace  of  pus  has  been  sponged  or  washed 
away  one  or  more  tubes  should  extend  from  the  abdominal 
wound  into  every  recess  of  the  suppurating  region  and  each 
surrounded  with  au  iodoform -gauze  packing.  The  sponge 
protectives  are  then  removed  and  their  places  supplied  by 
strips  of  iodoform  gauze,  the  upper  and  lower  angles  of  the 
wound  are  sutured  in  the  usual  way,  and  a  strip  of  iodo- 
form gauze  placed  over  the  intestines  beneath  them.  The 
ends  of  all  the  strips  of  gauze  are  brought  out  at  the  centre 
of  the  wound  and  counted. 

After  the  first  twelve  to  twenty-four  hours  the  dressings 


412  OPERATIVE  SURGERY. 

will  probably  be  saturated  with  the  blood-stained  serous 
discharge  and  need  changing,  which  then  and  afterward 
must  be  done  with  every  antiseptic  precaution.  The  gauze 
directly  beneath  the  suture  line  can  probably  be  removed 
in  twenty-four  to  forty-eight  hours,  but  it  will  require  a 
vigorous  pull. 

STOMACH. 

Anatomy.  The  cardiac  orifice  lies  about  one  inch  to  the 
left  of  the  sternum  beneath  the  seventh  left  costal  cartilage. 
The  pyloric  orifice  in  the  empty  stomach  lies  in  the  median 
line  or  close  to  the  right  of  it  and  two  or  three  inches  below 
the  end  of  the  gladiolus,  and  is  in  relation  with  the  neck 
of  the  gall-bladder,  the  portal  vein,  the  gastro-duodenalis, 
and  right  gastro-epiploica  arteries,  the  pancreas,  and  the 
splenic  vein.  The  lesser  curvature  is  connected  with  the 
transverse  fissure  of  the  liver  by  the  lesser  omentum,  which 
contains  from  left  to  right  the  gastric,  pyloric,  and  hepatic 
arteries,  the  portal  vein,  and  common  bile  duct.  The  great 
omentum  passes  downward  from  the  greater  curvature,  on 
which  lie  the  right  and  left  gastro-epiploica  arteries,  across 
the  colon,  to  which  the  anterior  layer  is  generally  adherent, 
the  posterior  always.  The  transverse  mesocolon  is  near  the 
posterior  surface  of  the  stomach.  The  left  lobe  of  the  liver 
descends  in  front  of  the  stomach  a  variable  distance,  gen- 
erally not  below  the  ninth  left  costal  cartilage.  When 
the  stomach  is  distended,  it  is  in  contact  with  the  anterior 
abdominal  wall  over  quite  a  large  area  below  the  left  lobe 
of  the  liver;  when  it  is  empty,  this  area  of  contact  becomes 
very  small,  and  lies  between  the  left  lobe  of  the  liver  and 
a  transverse  line  drawn  at  the  level  of  the  anterior  end  of 
the  ninth  rib.  The  guide  to  this  line,  as  Tillaux  has  shown, 
is  the  anterior  end  of  the  tenth  rib,  which  can  be  readily 
felt  projecting  beyond  the  border  of  the  cartilages  of  the 
false  ribs,  and  can  be  made  to  yield  a  sort  of  friction  sound 
by  rubbing  it  against  the  ninth.  Sedillot  claimed  that 
when  the  stomach  was  empty,  it  was  nowhere  in  contact 
with  the  anterior  abdominal  wall,  being  separated  from  it 
by  the  liver  and  transverse  colon,  and  recommended  that  it 
should  be  approached  by  a  crucial  incision  through  the  left 
rectus  muscle  two  or  three  inches  below  the  xiphoid  appen- 


SPECIAL  OPERATIONS. 


413 


dix  of  the  sternum.  He  passed  his  finger  along  the  border 
of  the  left  lobe  of  the  liver  to  the  diaphragm,  encountered 
the  stomach  there,  seized  it  with  pronged  forceps  introduced 
along  the  finger,  and  drew  it  up  to  the  incision  while  press- 
ing the  colon  downward.  Although,  as  stated,  more  recent 
investigations  have  shown  that  the  normal  stomach  when 
empty  is  still  in  contact  with  the  anterior  abdominal  wall, 
these  directions  for  finding  the  stomach  may  be  useful  in 
cases  where  it  has  been  drawn  back  and  bound  down  to  the 
posterior  wall  by  inflammatory  adhesions  or  neoplasms. 

GASTROSTOMY. 

It  consists  in  the  establishment  of  a  fistula  through  the 
walls  of  the  stomach  and  abdomen. 

Operation.  An  incision  one  and  a  half  or  two  inches 
long  is  made  parallel  to  and  a  finger-breadth  from  the  free 
border  of  the  left  costal  cartilage,  ending  below  opposite 

Pig.  219. 


Anatomical  relations  of  the  stomach  with  reference  to  gastrostomy. 


the  end  of  the  tenth  rib.  The  tissues  are  divided  layer  by 
layer,  the  peritoneum  pinched  up  and  opened.  When  the 
stricture  is  close  the  stomach  and  intestines  are  usually 
empty  and  the  abdomen  deeply  sunken  by  atmospheric 
pressure.  In  such  cases,  when  each  successive  layer  is 
divided  it  rises  from  the  underlying  mass,  and  when  the 
peritoneum  is  opened  the  air  rushes  in  and  the  abdominal 
wall  rises  away  from  the  stomach  and  becomes  level  with 
the  sternum  and  ribs.  The  stomach  is  recognized  just 
below  the  left  lobe  of  the  liver  by  its  white  color,  smooth 
surface,  and  the  arrangement  of  its  arteries.     If  it  does  not 


414 


OPERATIVE  SURGERY. 


present  in  the  wound  the  transverse  colon  and  omentum 
are  pressed  down,  the  fingers  passed  up  under  the  left  lobe 
of  the  liver  and  to  the  left  close  to  the  diaphragm  and 
vertebral  column,  and  the  lesser  curvature  sought  for. 
When  found  a  fold  of  the  stomach  is  picked  up  by  the 
fingers  aud  a  spot  fixed  upon  which  avoids  too  much  trac- 
tion and  is  suitable  for  a  fistula.  The  method  now  in  favor 
in  gastrostomy  is  to  stitch  the  parietal  peritoneum  to  the 
skin  all  around  the  incision,  and  then  to  fasten  the  un- 
opened stomach  in  the  wound  by  several  sutures  which 


Diagram  to  show  a  method  of  fastening  the  stomach  in  a  wound  of  the  abdominaJ 
parietes.    (Greig  Smith.) 


traverse  its  muscular  coat  but  do  not  enter  its  cavity,  and 
whose  deeper  ends  then  transfix  the  abdominal  wall.  This 
gives  a  broad  surface  of  contact  between  the  peritoneum  of 
the  stomach  and  that  of  the  abdominal  wall,  and  favors 
their  prompt  union.  The  protruding  portion  of  the  stomach 
may  also  be  transfixed  with  two  long  pins  which  rest  upon 
the  skin  and  prevent  strain  on  the  sutures.  The  opening 
of  the  stomach  is  delayed  as  long  as  possible,  from  one  to 
eight  days.  If  necessary,  food  can  be  introduced  by  punc- 
turing with  an  aspirating  needle. 


SPECIAL  OPERATIONS.  41 5 

Another  method,  after  stitching  together  the  parietal 
peritoneum  and  skin,  is  to  pass  two  retention  sutures  of 
silver  wire  through  about  half  an  inch  of  the  stomach  wall, 
and  about  the  same  distance  apart.  A  continuous  silk 
suture  is  next  passed  through  the  wall  of  the  viscus  in  a 
circle  about  two  inches  in  diameter  and  brought  out  and 
reinserted  at  intervals  of  a  quarter  of  an  inch,  leaving 
numerous  free  loops  on  its  surface.  (Fig.  220.)  No  suture 
must  enter  the  interior  of  the  stomach.  Each  loop,  as 
made,  is  passed  through  the  abdominal  wall  at  the  margin 
of  the  incision  and  threaded  on  a  rubber  tube,  around 
which  the  wire  retention  sutures  are  also  passed  to  assist  in 
holding  the  stomach.     (Fig.  221.) 

Fig.  221. 


Completion  of  operation  represented  in  Fig.  220. 

Witzie1  divides  the  skin  parallel  to  the  ribs  and  a  finger's 
breadth  distant,  then  the  rectus  muscle  longitudinally,  and 
the  transversalis  horizontally.  Next  the  anterior  wall  of 
the  stomach  is  drawn  into  the  abdominal  wound  sufficiently 
to  permit  of  its  being  folded  lengthwise  and  sutured  over 
a  rubber  tube,  which  at  one  extremity  enters  the  viscus  and 
at  the  other  is  brought  out  of  the  openiug  in  the  skin.  The 
stomach  is  then  fastened  in  the  wound  in  the  ordinary  way 
by  a  row  of  sutures  around  the  folds  enclosing  the  tube, 

1  Centralbl.  f.  Chir.,  1891,  p.  601. 


41 6  OPERA TIYE  SUB QER  Y. 

and  over  the  latter  the  skin  is  united,  leaving  only  a  small 
hole  for  the  exit  of  the  tube.     This  is  intended  to  make 
the   fistula   communicate   less  directly 
■    r^""  with  the  surface  of  the  body,  and  thus 

insure  better  retention  of  the  gastric 
contents.  It  is  important  that  the  tube 
should  fill  and  even  distend  the  orifice 
by  which  it  enters  the  stomach. 

The  leakage  from  a  straight  fistula  of 
this  organ  can,  however,  be  controlled 
to  a  certain  extent  by  a  mechanical  de- 
vice consisting  of  two  hollow  rubber 
disks  closely  joined  at  their  centres  by  a 
Plug  of  two  hollow  hollow  rubber  cylinder  communicating 
r^d^v0rn0Sir     with  each.     The  lower  disk  is  passed 

a  gastrostomy  w  ound.  .  .        .  .  tr 

through  the  fistula  into  the  stomach, 
and  both  disks  are  then  distended  with  air  or  water  and 
thus  made  to  block  the  opening. 

In  cases  where  the  stomach  need  not  be  opened  for  some 
days  it  is  sufficient,  after  uniting  the  skin  and  parietal 
peritoneum,  to  pass  a  couple  of  harelip  pins  through  its 
outer  coats,  enclosing  a  portion  of  the  stomach  wall  about 
three-quarters  of  an  inch  square.  The  pins  are  simply  laid 
upon  the  skin  transversely  to  the  abdominal  wound,  and 
the  opening  made  in  the  centre  of  the  square  they  enclose 
after  adhesions  have  formed. 

A  crucial  abdominal  incision  below  the  ensiform  process 
was  used  by  Sedillot.  Others  have  employed  a  vertical  in- 
cision in  the  linea  alba,  in  the  substance  of  the  outer  part  of 
the  left  rectus,  or  in  the  left  linea  semilunaris. 

Hahn  opened  and  fixed  the  stomach  in  the  eighth  inter- 
costal space  after  first  entering  the  abdomen  by  an  incision 
parallel  with  the  lowest  rib.1 


GASTKOTOMY. 

This  is  the  operation  in  which  the  surgeon  opens  the 
stomach  and  then  closes  it  at  the  conclusion  of  the  opera- 
tion. 

1  Centralb.  f.  Chir.,  1890,  p.  193. 


SPECIAL  OPERATIONS.  417 

Operation.  If  it  is  performed  for  the  removal  of  a  for- 
eign body  which  can  be  felt  through  the  anterior  abdominal 
wall,  the  incision,  at  least  two  inches  long,  is  made  over  the 
tumefaction  and  in  the  direction  which  inflicts  the  least 
damage  on  the  intervening  tissues.  Otherwise  the  incision 
is  made  in  the  median  line  just  below  the  ensiform  process 
or  parallel  to  the  left  costal  cartilages,  as  in  gastrotomy. 
The  tissues  are  divided  layer  by  layer,  the  peritoneum 
opened,  and  one  finger  introduced  to  locate  the  foreign 
body. 

After  protecting  the  surrounding  peritoneal  surface  by 
gauze  pads  or  sponges,  the  part  of  the  stomach  wall  to  be 
opened  is  carefully  drawn  into  the  abdominal  wound  and 
held  there  by  a  couple  of  temporary  retention  sutures  passed 
through  the  peritoneal  and  muscular  coats  on  each  side  of 
the  intended  opening,  which  is  then  made  parallel  to  the 
course  of  the  bloodvessels,  that  is,  transversely  to  the  long 
axis  of  the  stomach.  The  foreign  body  is  removed  gently, 
with  due  regard  for  its  sharp  points,  or  the  ulceration  or 
sloughing  which  may  exist,  and  if  necessary  the  stomach 
is  washed  out.  There  must  be  as  little  sponging  or  irrita- 
tion of  its  interior  as  possible. 

The  incision  in  the  stomach  is  closed  by  a  continuous 
silk  suture  of  the  mucous  membrane,  then  by  a  row  of 
Lembert  sutures,  which  are  reinforced  by  a  continuous 
silk  suture  through  the  peritoneal  coat.  After  the  region 
of  the  wound  has  been  made  dry  and  clean,  the  temporary 
retention  sutures  are  withdrawn,  the  protecting  sponges  are 
removed  from  the  abdominal  cavity  and  the  parietal  wound 
closed  and  dressed  as  described  for  an  aseptic  laparotomy. 

Greig  Smith  does  not  suture  the  mucous  membrane  of  the 
stomach,  but  closes  the  wound  by  a  row  of  Lembert  sutures 
reinforced  by  a  continuous  or  interrupted  suture  of  the 
peritoneal  coat.  The  continuous  suture  prevents  gaping 
of  the  wound  during  expansion  of  the  stomach. 

By  gastrotomy  Bull1  and  Richardson  successfully  re- 
moved foreign  bodies  impacted  in  the  cesophagus  near  the 
cardiac  orifice  of  the  stomach.  Richardson  demonstrated 
that   the   lower  three  inches  of  the   oesophagus  are  thus 

1  New  York  Medical  Journal,  October  29,  1887. 


418  OPERATIVE  SURGERY. 

accessible  by  an  incision  parallel  to  the  left  costal  cartilages, 
through  which  he  introduced  his  whole  hand  into  the 
stomach  and  extracted  a  set  of  false  teeth  from  the  lower 
end  of  the  gullet.1 

Gaslrotomy  for  Benign  Stenosis  of  the  Pyloric  or  Cardiac 
Orifices.  (Sometimes  called  Loretta's  operation.)  Before  the 
operation  the  stomach  is  washed  out  repeatedly  with  an  alka- 
line solution.  The  pylorus  is  reached  by  an  incision  four  or 
five  inches  long,  usually  in  the  linea  alba  between  the  xiphoid 
appendix  and  the  umbilicus  ;  or  else  approximately  parallel 
to  and  about  an  inch  from  the  right  costal  cartilages,  starting 
an  inch  below  and  an  inch  and  a  half  to  the  left  of  the 
xiphoid  appendix  and  terminating  near  the  level  of  the 
cartilage  of  the  ninth  rib.  The  tissues  are  divided  layer 
by  layer,  and  the  peritoneum  opened.  The  surrounding 
peritoneal  surface  is  protected  and  held  out  of  the  way  in  the 
usual  manner,  while  the  pylorus  is  sought  for,  and  such 
adhesions  as  may  exist  are  divided  between  double  catgut 
ligatures.  The  anterior  wall  of  the  stomach  is  drawn  into  the 
abdominal  wound,  and  after  again  carefully  protecting  the 
surrounding  peritoneal  surface  is  incised  transversely  for 
from  one  to  three  inches  between  its  two  curvatures  near 
the  pylorus,  but  outside  of  the  inflammatory  zone  adjoin- 
ing it.  Guided  by  two  fingers  grasping  the  pylorus  ex- 
ternally, the  forefinger  of  the  right  hand  is  passed  through 
the  stomach  into  the  pyloric  orifice.  This  may  require 
considerable  force,  or  the  orifice  may  have  become  so  con- 
tracted that  preliminary  dilatation  with  some  small  instru- 
ment is  necessary. 

McBurney  used  a  small  bivalve  anal  speculum.  Dilata- 
tion is  continued  till  it  is  felt  that  any  further  stretching 
would  threaten  a  rupture  of  the  viscus.  The  wound  in  the 
stomach  in  then  sutured  as  described  in  gastrotomy  for  a 
foreign  body,  and,  after  cleansing  and  drying  the  field  of 
operation  and  removing  the  protective  pads  or  sponges,  the 
parietal  wound  is  closed  as  usual. 

To  reach  the  cardiac  orifice,  the  abdominal  incision  is 
made  obliquely  from   a  point  just  below  the  ensiform  pro- 

1  Lancet,  October  «,  1837. 


SPECIAL  OPERATIONS. 


419 


cess  parallel  to  and  about  one  inch  from  the  left  costal  car- 
tilages. The  anterior  wall  of  the  stomach  is  opened  by  a 
longitudinal  incision  made  between  the  two  curvatures  and 
as  near  the  cardiac  end  as  possible. 

Instead  of  performing  gastrotomy  and  divulsion  of  the 
pylorus,  the  stricture  can  be  relieved  by  longitudinal  divi- 
sion followed  by    transverse  reunion.     (Fig.  223.)     The 

Fig.  223. 


B  A 

Pyloroplasty. 

A.  The  incision,  A,  B,  along  the  contracted  pylorus. 

B.  Closure  of  this  wound  transversely.    The  point  A  united  to  B. 


median  or  right  oblique  abdominal  incision  is  employed, 
any  adhesions  about  the  pylorus  are  separated,  and  after 
carefully  walling  off  the  surrounding  peritoneum  with 
sponges  an  incision  opening  the  lumen  of  the  viscera  about 
an  inch  and  a  half  long  is  carried  across  the  pyloric  ring, 
through  the  neighboring  anterior  wall  of  the  stomach  and 
first  part  of  the  duodenum.  The  opposite  extremities  of 
this  incision  are  then  united  to  each  other  to  form  the  centre 
of  an  apparently  transverse  wound,  Fig.  223,  which  is 
closed  by  the  Czerny-Lembert  suture.  The  protecting 
sponges  are  removed  from  the  cleaned  and  dried  peritoneal 
cavity,  and  the  parietal  iucision  closed  tight  in  the  usual 
way. 

After  relieving  the  pyloric  stenosis,  the  dilatation  of  the 
stomach  has  been  lessened  by  taking  a  "  tuck  "  in  its  au- 
terior  wall,  a  longitudinal  fold  of  which  is  pushed  into  the 
lumen  of  the  viscus,  and  the  opposite  external  margins  of 
the  inverted  part  united  by  Lembert  sutures. 


420  OPERATIVE  SURGERY. 


GASTRORRAPHY. 

This  is  the  operation  for  closing  a  wound  or  opening  in 
the  stomach. 

Operation.  If  it  is  undertaken  to  close  a  gastric  fistula, 
the  interior  of  the  stomach,  the  fistulous  tract,  and  surround- 
ing skin  are  made  as  clean  as  possible.  A  sponge  tied  to  a 
string  is  pushed  through  the  fistula  aud  held  by  au  assistant 
against  its  interior  orifice.  An  incision  is  then  made  not 
less  than  two  inches  long  in  a  vertical  or  auy  convenient 
direction  across  the  fistula  and  through  the  abdominal  wall, 
layer  by  layer,  until  the  peritoneum  is  reached.  This  is 
opened  at  one  extremity  of  the  wound  and  a  finger  inserted 
to  determine  the  limit  of  the  adhesions.  On  this  finger  as 
a  director,  the  peritoneal  incision  is  enlarged  around  the 
fistula,  which  is  then  surrounded  by  sponges  packed  into 
the  abdominal  cavity.  The  liberated  stomach  is  drawn  into 
the  abdominal  wound,  and  the  margins  of  the  opening  in 
the  stomach  freshened  and  closed  as  described  in  gastrot- 
omy,  after  withdrawing  the  sponge  from  the  interior  of 
the  stomach. 

The  fistulous  tract  is  excised  from  the  abdominal  wall, 
and,  after  the  operation  area  has  been  thoroughly  cleansed 
and  dried  and  the  protecting  sponges  removed  from  the 
abdomen,  the  wound  is  closed  in  the  usual  way  with  or 
without  a  gauze  packing. 

If  the  operation  is  undertaken  for  a  perforating  wound 
or  ulcer  of  the  stomach,  immediately  after  opening  the 
peritoneal  cavity  by  an  ample  incision,  either  median,  just 
below  the  ensiform  process,  or  parallel  to  the  left  costal 
cartilages,  all  extravasated  material  must  be  sponged  away 
or  irrigated  out  of  the  peritoneal  cavity  with  boiled  water, 
and  the  opening  in  the  stomach  closed  as  described  in 
gastrotomy.  The  operation  area  is  walled  around  by 
sponges  or  puds  and  a  sponge  is  then  passed  into  the  lesser 
peritoneal  sac  through  a  small  opening  made  in  the  great 
omentum,  between  the  stomach  and  transverse  colon.  If 
the  lesser  sac  is  found  infected,  or  there  is  even  a  suspicion 
of  an  opening  on  the  posterior  surface  of  the  stomach,  this 


SPECIAL  OPERATIONS.  421 

opening  must  be  sought  for  and  closed.  If  it  cannot  be 
reached  and  sutured  through  the  great  omentum  (between 
the  stomach  and  transverse  colon),  rather  than  leave  it 
unclosed,  Greig  Smith  advises  an  incision  in  the  anterior 
wall  of  the  stomach,  and  through  this  suturing  the  opening 
in  the  posterior  surface  from  within.  After  everything  has 
been  made  as  clean  as  possible,  and  all  sponges  removed 
from  the  abdominal  cavity,  tubes  surrounded  by  a  plentiful 
gauze  packing  should  extend  into  all  the  infected  regions 
in  the  greater  and  lesser  peritoneal  sacs  and  connect  them 
with  the  skin  surface. 

The  parietal  wound  is  then  partially  closed  and  dressed 
antiseptically. 

PYLORECTOMY. 

The  stomach  should  be  repeatedly  washed  previously  and 
should  be  empty  at  the  time  of  operation.  The  abdominal 
incision  is  made  in  the  linea  alba  between  the  ensiform  process 
and  umbilicus,  or  over  the  most  prominent  part  of  the  tumor, 
and  more  or  less  transversely,  from  just  to  the  left  of  the 
median  line  in  the  direction  of  the  free  border  of  the  right 
costal  cartilages  and  not  less  than  an  inch  from  them. 
Other  forms  of  incision  that  have  been  employed  are 
vertical  at  the  outer  border  of  the  right  rectus,  transverse 
over  the  tumor,  or  crucial.  At  first  the  incision  is  only 
made  large  enough  for  exploration.  If  then  the  operation 
is  deemed  feasible,  it  is  enlarged  till  it  is  from  three  to  five 
inches  long. 

Sponges  are  packed  into  the  abdomen  around  the  tumor, 
which  is  drawn  as  much  as  possible  into  the  abdominal 
wound.  The  great  and  small  omenta  are  cut  close  to  the 
greater  and  lesser  curvatures  of  the  stomach,  after  first 
securing  the  vessels  between  double  ligatures,  till  the  point 
toward  the  left  is  reached  where  the  stomach  wall  is  to  be 
divided.  Great  care  must  be  taken  not  to  wound  the  portal 
vein,  hepatic  artery,  or  common  bile  duct  which  lie  behind 
the  pylorus,  and  no  damage  must  be  done  to  the  transverse 
mesocolon.  If  the  disease  involves  this  structure  the 
operation  should  be  abandoned, 

Fresh  sponges  are  now   packed   around   the   liberated 

19 


422 


OPERATIVE  SURGERY. 


pyloric  end  of  the  stomach,  and  the  growth,  with  a  margin 
of  healthy  tissue,  is  excised  with  scissors.  All  vessels  are 
secured  as  they  are  divided,  the  lumen  of  the  duodenum  is 
immediately  plugged  by  a  sponge,  aud  after  removing  all 
extra vasated  matter  aud  renewing  the  sponge  packing  around 
the  field  of  operation,  the  large  opening  in  the  stomach  is 
narrowed  on  the  side  of  the  lesser  curvature  by  Czerny- 
Lembert  sutures  till  the  opeuiug  which  remains  next  the 
greater  curvature  approximates  the  size  of  the  duodenum. 
If  circumstances  require  the  implautation  of  the  duodenum 


Fig.  224. 


Pylorectomy.     Showing  method  of  narrowing  the  opening  in  the  stomach. 


near  the  lesser  curvature,  the  opening  in  the  stomach  is 
narrowed  below  or  on  both  sides  in  the  same  way  (Fig, 
224),  the  posterior  walls  of  the  stomach  and  duodenum  at 
their  respective  points  of  division  are  then  approximated 
and  the  margins  of  the  wounds  behind  are  inverted  to 
bring  the  posterior  peritoneal  surfaces  in  contact. 

The  redundant  mucous  membrane  is  raised  at  its  cut 
edge  and  sutures  of  fine  silk  arc  passed  beneath  it  from  the 
inside,  at  intervals  of  an  eighth  of  an  inch,  through  the 
muscular  and  peritoneal  coats  of  the  stomach  and  duodenum. 
When  knotted  the  sutures  lie  beneath  the  mucous  mem- 
brane, which  can  be  closed  over  them  by  a  continuous  or 
interrupted  suture  (Fig.  225),  only  about  the  posterior  half 
of  the  stomach  and  duodenum  can  be  united  in  this  way. 

The  sponge  is  then  withdrawn  from  the  duodenum  and 
the    remainder  of   the   wound    is  closed   by   the  Czerny- 


SPECIAL  OPERATIONS. 


423 


Lembert  suture.  After  testing  the  suture  line  by  filling 
the  stomach  with  water,  the  operation  area  is  made  clean 
and  dry,  the  protective  sponge  packing  is  removed,  and  the 
abdominal  wound  is  closed  in  the  usual  way. 

Senn's  omental  graft  to  surround  the  suture  line  in  the 
viscera  might  be  useful. 

In  extensive  resections  of  the  pylorus,  Billroth  and 
others  have  closed  the  resulting  wounds  in  the  stomach  and 

Fig.  225. 


Wolfler's  methods  of  uniting  the  wound  in  the  posterior  portion  of  the  stomach 
after  pylorectomy.    The  shaded  line  represents  the  mucosa. 

duodenum  by  Lembert  sutures  and  then  restored  the  con- 
tinuity of  the  alimentary  canal  by  performing  a  gastro- 
enterostomy. 

On  account  of  the  high  mortality  of  pylorectomy  for 
malignant  disease,  this  operation  is  now  rarely  done ;  in 
general  it  may  be  stated  that  when  the  tumor  can  be  felt 
through  the  anterior  abdominal  wall,  it  is  scarcely  justifi- 
able to  attempt  its  removal. 


GASTROENTEROSTOMY. 


The  preliminary  washing  of  the  stomach  and  the  abdom- 
inal incision  are  the  same  as  for  pylorectomy,  but  the 
abdomen  is  more  commonly  opened  in  the  median  line 
between  the  ensiform  process  and  the  umbilicus.  The  first 
loop  of  intestine  which  presents  is  grasped  and  traced  up- 


424 


OPERATIVE  SURGERY. 


ward  to  the  duodenum.  It  should  be  noted  that  this  part 
of  the  gut  is  thicker,  of  greater  diameter,  aud  more  vascu- 
lar than  that  nearer  the  colon.  Czerny  advises  that  the 
origin  of  the  jejunum  be  sought  for  at  once  by  drawing  up 
the  stomach,  great  omentum,  and  transverse  colon,  and  fol- 
lowing back  the  transverse  mesocolon  to  the  spine ;  imme- 
diately to  the  left  of  this  lies  the  end  of  the  duodenum. 
A  portion  is  then  selected  as  near  to  the  latter  as  will  per- 
mit easy  coaptation  with  the  stomach,  the  great  omentum 
is  pushed  to  the  left  and  the  intestine  drawn  to  the  right 

Fig.  226. 


Gastroenterostomy ;  diagram  to  show  the  method  of  union  to  secure  similarity  in 
direction  of  the  peristalsis  of  the  stomach  and  intestine. 


and  upward  over  the  colon.  The  anterior  wall  of  the 
stomach  near  the  greater  curvature  and  the  selected  por- 
tion of*  intestine  are  drawn  as  far  as  possible  into  the  ab- 
dominal wound,  and  the  loop  of  intestine  should  be  so 
twisted  or  placed  that  at  the  conclusion  of  the  operation 
the  direction  of  its  peristaltic  wave  shall  not  be  opposite 
to  that  of  the  stomach.     (Fig.  226.) 


SPECIAL  OPERATIONS.  425 

The  rest  of  the  abdominal  contents  are  walled  off  by  a 
protective  sponge-packing,  and  the  selected  loop  of  intestine, 
squeezed  empty  by  the  fingers,  is  prevented  from  filling  by 
a  rubber  or  gauze  band  passed  through  the  mesentery  and 
constricting  each  extremity  of  the  selected  loop. 

A  continuous  silk  suture  through  the  peritoneal  and 
muscular  coats  is  then  made  to  unite  the  anterior  sur- 
face of  the  stomach  near  its  greater  curvature  to  the  pos- 
terior surface  of  the  intestine  a  little  to  the  mesenteric  side 
of  its  free  border,  for  about  four  inches. 

In  addition,  a  row  of  Lembert  sutures  may  be  placed 
anterior  to  the  continuous  suture,  although  this  is  not  abso- 
lutely necessary.  After  the  rest  of  the  abdominal  contents 
are  protected  from  extravasated  matter  by  fresh  sponges, 
the  stomach  and  intestine  are  opened  parallel  and  close  to 
this  suture  line,  and  the  interiors  of  each  irrigated  clean — 
the  incisions  should  terminate  opposite  each  other  and  about 
half  an  inch  short  of  the  extremities  of  the  suture  line. 
Having  made  the  wounds  and  their  surroundings  clean 
and  dry,  the  adjoining  posterior  margins  of  the  two  incis- 
ions are  rapidly  sewn  together  by  a  continuous  suture 
passed  through  the  entire  thickness  of  the  walls,  and  this 
suture  is  continued  as  far  as  possible  around  each  angle  of 
the  incision  and  along  the  anterior  margins.  The  opera- 
tion is  then  completed  by  a  row  of  Lembert  sutures  or  a 
continuous  suture  extending  along  the  auterior  surface  from 
one  end  to  the  other  of  the  first  suture  line. 

The  constricting  baud  at  each  extremity  of  the  loop  of 
intestine  is  then  removed,  all  parts  are  made  clean  and 
dry,  the  surrounding  sponge-packing  is  taken  out  and 
counted,  the  viscera  replaced,  and  the  abdominal  wound 
closed  tight  in  the  usual  way. 

Some  German  surgeons,  before  uniting  the  stomach  with 
the  loop  of  small  intestine,  pass  the  latter  through  the 
great  omentum  aud  over  the  colon,  or  through  a  vertical 
slit  in  the  transverse  mesocolon  and  then  through  the  gastro- 
colic ligament  to  the  anterior  surface  of  the  stomach.  But 
the  route  to  the  right,  around  the  great  omentum,  is  to  be 
preferred  whenever  possible. 

Jejunostomy  for  inoperable  cancer  of  the  pylorus  has 
been  performed  a  few  times.     A  longitudiual  incision  is. 


426  OPERATIVE  SURGERY. 

made  to  the  left  of  the  umbilicus,  the  omentum  and  trans- 
verse colon  pressed  upward,  and  a  loop  of  the  upper  portion 
of  the  jejunum  brought  into  the  wound  and  secured  there 
by  sutures  as  in  gastrostomy.  The  opening  made  in  the 
intestine  should  be  only  large  enough  to  admit  the  tube 
through  which  food  is  to  be  introduced. 

Maydl  has  proposed  a  more  complicated  method,  as  fol- 
lows : 

The  abdomen  is  opened  transversely  about  four  finger- 
breadths  below  the  ensiform  process,  a  loop  of  jejunum 
some  ten  or  twelve  inches  long  extracted,  and,  with  every 
antiseptic  precaution,  divided  transversely.  The  proxi- 
mal segment  is  then  connected  with  the  distal  a  few 
inches  below  the  point  of  division  by  an  anastomosis  opera- 
tion to  preserve  the  biliary  and  pancreatic  secretions,  and 
the  distal  segment  fixed  in  the  abdominal  wound  as  in  gas- 
trostomy,1 or  the  distal  segment  may  be  attached  to  the 
stomacli  thus  making  a  gastroenterostomy. 


HERNIOTOMY,  KELOTOMY. 

Under  this  head  are  to  be  described  the  operations  for 
the  relief  of  strangulated  inguinal,  femoral,  umbilical,  and 
obturator  hernias,  and  those  for  the  radical  cure  of  the  first 
three  varieties. 

It  has  been  well  said  that  there  is  no  operation  in  which 
the  unforeseen  has  a  larger  share  than  in  herniotomy,  none 
in  which  the  surgeon  is  called  upon  to  show  more  skill, 
sagacity,  and  decision.  The  causes  of  this  are  to  be  found 
in  the  absence  of  absolute  guides  to  the  hernial  sac,  the 
changes  in  the  sac  and  overlying  tissues  brought  about  by 
inflammation  or  time,  the  character  of  the  hernia — whether 
composed  of  omentum,  intestine,  caecum,  or  bladder,  and, 
lastly,  the  difficulty  of  determining  not  only  the  extent  of 
the  injury  done  to  the  strangulated  tissues,  but  even,  in 
some  cases,  the  route  taken  by  the  hernia  in  its  descent. 
It  is  desirable,  therefore,  that  the  account  of  the  different 
operations  should  be  preceded  by  some  general  considera- 
tions upon  these  subjects. 

1  Maydl  :  Wii-n.  med.  WochenBCh.,  L892,  p.  697. 


SPECIAL  OPERATIONS.  427 

General  Directions.  A.  Recognition  of  the  Sac  and 
Bowel.  The  first  difficulty  encountered  in  the  course  of 
the  operation  is  that  of  recognizing  the  sac.  The  thickness 
of  the  connective  tissue  covering  it  varies  greatly  in  different 
cases;  each  layer  must  be  pinched  up  with  forceps,  opened 
with  the  knife  lying  upon  its  side,  as  in  opening  the  sheath 
of  an  artery,  then  raised  upon  the  finger  or  a  director,  and 
divided  to  the  full  extent  of  the  cutaneous  incision,  after 
having  been  carefully  scrutinized.  Occasionally  a  cyst 
containing  liquid  is  found  in  front  of  the  hernia,  and  may 
at  first  be  mistaken  for  it,  for  usually  the  sac  contains  a 
certain  amount  of  serum.  Careful  examination  of  the  tissues 
before  division  is  absolutely  necessary,  because  in  those  rare 
cases  where  there  is  no  sac  (hernia  of  the  csecurn  or  of  the 
bladder),  and  in  others  where  it  is  quite  undistinguishable, 
it  is  only  by  recognizing  the  muscular  coat  when  he  reaches 
it,  that  the  surgeon  avoids  opening  the  intestine  or  bladder 
by  mistake.  As  the  sac  is  approached,  each  layer  should 
be  pinched  up  in  a  narrow  fold  and  moved  gently  across 
the  underlying  parts ;  if  a  smooth  globular  tumor  is  felt 
below,  the  surgeon  makes  an  opening  in  the  fold,  confident 
that  the  wall  of  the  intestine  is  not  included  in  it;  but 
if  he  is  unable  to  pinch  up  the  fold,  or  if,  instead  of  the 
sensation  of  a  smooth  globular  mass,  he  gets  only  that  of 
an  empty  space,  he  examines  the  surface  again,  divides  any 
fibrous  bands  he  may  find  at  the  neck  of  the  hernia,  and 
tries  to  introduce  his  finger  through  it  into  the  abdominal 
cavity.  If  he  succeeds,  he  knows  the  sac  has  been  opened ; 
if  he  does  not  succeed,  he  renews  the  examination  and  con- 
tinues the  dissection. 

Maisonneuve  said  the  surgeon  may  know  he  has  not 
reached  the  intestine  so  long  as  he  is  not  certain  of  having 
done  so ;  but  this  is  not  true  of  all  cases ;  the  intestine  is 
not  always  smooth  and  shining;  it  may  be  dark,  dull,  con- 
gested, and  thickened,  and  in  hernia  of  the  caecum  or 
sigmoid  flexure  it  may  have  no  peritoneal  coat. 

When  the  hernia  is  small  and  recent  the  sac  is  bluish, 
and  can  be  pinched  up  between  the  thumb  and  finger,  so 
that  its  smooth  opposing  surface  can  be  felt  to  glide  upon 
one  another.  When  it  is  large  and  of  long  standing,  the 
sac  may  be  exceedingly  thin  and  unrecognizable,  or  very 


428  OPERATIVE  SURGERY. 

thick  and  adherent.  If  small,  it  should  be  thoroughly 
isolated,  and  its  boundaries  everywhere  defined;  if  large 
and  adherent,  its  neck  alone  should  be  cleared. 

B.  Opening  of  the  Sac.  The  propriety  of  opening  the 
sac  used  to  be  a  subject  of  dispute.  The  only  objection  to 
it,  but  that  a  serious  one,  was  the  danger  of  thereby  setting 
up  peritonitis.  On  the  other  side  there  was  the  danger  of 
returning  the  hernia  into  the  abdomen  in  a  gangrenous 
condition,  or  unreduced  when  the  stricture  was  formed  by 
the  sac  itself.  Now,  however,  the  rule  is  always  to  open 
the  sac  with  every  antiseptic  precaution  and  relieve  any 
constriction  which  may  be  found  by  cutting  down  upon  it 
layer  by  layer  from  without.  Then  either  immediately  or 
after  au  interval  a  radical  cure  is  performed. 

The  liquid  which  is  usually  contained  in  the  sac  may  not 
only  serve  to  call  attention  to  its  accidental  opening,  but 
may  also  be  taken  advantage  of  to  open  it  safely  when  it 
has  been  recognized.  It,  of  course,  collects  at  the  most 
dependent  point,  and  there  intervenes  between  the  sac  and 
the  bowel,  so  that  the  former  can  be  pinched  up  and  opened 
without  injury  to  the  latter.  When  this  is  not  the  case, 
the  surgeon  must  pinch  up  a  very  small  fold  of  the  sac 
wherever  he  can  do  so,  or  do  as  Mr.  Liston  did  iu  a  case 
where,  as  he  says,  "there  was  no  possibility  of  pinching  up 
the  sac,  either  with  the  finger  or  forceps ;  it  contained  no 
fluid,  and  was  impacted  most  firmly  with  bowel;  very 
luckily  the  membrane  was  there;  and,  observing  a  pelleton 
of  fat  underneath,  I  scratched  very  cautiously  with  the 
point  of  the  knife  in  the  unsupported  hand,  until  a  trifling 
puncture  was  made,  sufficient  to  admit  the  blunt  point  of 
a  narrow  bistoury."1  The  opening  should  be  enlarged 
until  the  finger  can  be  introduced,  and  then  the  sac  slit  up 
on  it  as  a  guide.  If  the  omentum  is  then  found  filling  the 
sac,  it  must  be  cautiously  unfolded  or  incised,  for  it  is 
probable,  especially  in  umbilical  hernia,  that  a  strangulated 
loop  of  intestine  will  be  found  in  its  centre. 

0.  Division  of  the  Stricture.  The  left  forefinger  is 
passed  up  into  the  neck  of  the  sac  by  which  the  stricture 
is  usually  constituted,  the  pulp  upward,  the  nail  pressing 

1  Op.  Surgery,  p.  402,  quoted  by  Jos.  Hell,  Manuulof  Surgical  Operations,  p.  231. 


SPECIAL  OPERATIONS.  429 

against  the  intestines ;  if  the  stricture  lies  or  can  be  drawn 
outside  the  opening  in  the  abdominal  wall  through  which 
the  hernia  made  its  escape,  it  may  be  divided  freely  without 
risk,  but  if  it  lies  within  the  opening  the  division  must  be 
made  with  reference  to  the  anatomy  of  the  region.  If  the 
division  cannot  be  made  at  the  desired  point,  but  only  at 
some  other  where  an  incision  of  the  necessary  extent  would 
be  daugerous,  the  stricture  must  be  slightly  nicked  at  that 
point,  and  advantage  then  taken  of  the  partial  liberation 
to  make  a  second  cut  in  the  proper  place. 

The  end  of  the  finger,  or  its  nail,  is  gently  engaged  in 
the  stricture,  its  pulp  against  the  selected  point  of  division, 
and  the  knife,  a  probe-pointed,  slightly  curved  bistoury, 
passed  on  the  flat  along  its  palmar  surface  until  the  point 
has  passed  through  the  stricture.  The  surgeon  then  turns 
its  edge  upward  and  presses  it  against  the  stricture  with 
the  end  of  the  finger  on  which  it  rests.  A  slight  crackling 
announces  the  division,  which  must  be  extended  or  repeated 
at  different  points  until  the  finger  can  be  passed  freely 
through  into  the  abdomen. 

Instead  of  an  ordinary  probe-pointed  bistoury,  a  specially 
constructed  hernia  knife  (Fig.  227)  is  often  used.     It  is 

Fig.  227. 


Hernia  knife. 

probe-pointed  and  its  cutting  edge  uot  more  than  an  inch 
long.  The  knife  may  also  be  guided  upon  a  director  in- 
stead of  the  finger.  The  "hernia  director"  is  broader  than 
the  ordinary  one,  and  sometimes  has  a  broad  flange  on  each 
side  to  keep  the  bowel  from  rolling  over  against  the  edge 
of  the  knife.  It  is,  however,  more  surgical  to  cut  down 
upon  the  constriction  layer  by  layer  and  then  divide  it 
from  without,  the  gut  being  protected  by  the  finger  or  a 
director. 

D.  Examination  and  Return  of  the  Bowel.     The  bowel. 

19* 


430  OPERA  TIVE  S UB GEB  Y. 

should  be  gently  drawn  out  about  an  iuch  in  order  that 
the  constricted  part  itself  may  be  examined,  for  it  is  very 
likely  to  be  badly  damaged.  If  the  entire  loop  is  in  suit- 
able condition  it  must  be  carefully  cleaned  of  all  blood  and 
gradually  returned  into  the  cavity  of  the  abdomen.  It  is 
not  always  easy  to  decide,  however,  whether  or  not  its 
condition  is  suitable  for  return,  and  some  surgeons  have 
recommended  that  in  cases  of  doubt  it  should  be  covered 
with  warm,  wet  cloths  and  kept  under  observation  for 
some  time,  the  stricture,  of  course,  having  been  previously 
divided. 

A  very  great  change  in  the  color  of  the  loop  is  far  from 
proving  the  existence  of  gaugrene.  A  deep  red  vinous, 
even  violet  color  does  not  preclude  recovery,  especially  if 
the  surface  has  not  lost  its  lustre  ;  but  if  it  is  black,  or  deep 
brown,  or  grayish-yellow,  or  if  it  is  dull,  flaccid,  or  wrinkled, 
it  is  certainly  gangrenous.  Of  course,  when  the  charac- 
teristic gangrenous  odor,  or  the  fecal  odor  consequent  on 
perforation,  exists,  there  can  be  no  doubt. 

If  the  loops  are  in  good  condition,  but  bound  fast  to  one 
another,  or  to  the  omentum,  or  to  the  sac  by  firm  adhe- 
sions, great  caution  must  be  exercised  in  dealiug  with  them. 
The  stricture  must  be  freely  divided  and  the  loops  emptied 
of  their  contents  by  pressure,  and  the  adhesions,  which 
have  probably  existed  for  a  long  time  without  inconve- 
nience to  the  patient,  should  in  most  cases  be  carefully 
separated. 

It  is  not  always  easy  to  return  the  intestines  even  after 
the  stricture  has  been  divided.  The  surgeon  should  try  to 
reduce  one  end  at  a  time,  by  squeezing  its  contents  back 
into  the  abdomen  and  pushing  the  gut  in  afterward.  If 
the  bowel  is  very  tense,  aud  the  hernial  orifice  cannot  be 
freely  enlarged,  the  gas  may  be  drawn  off  with  a  fine  aspi- 
rator. If  rupture  occurs,  and  the  bowel  is  otherwise  in 
good  condition,  it  must  be  closed  with  Lembert  sutures 
and  returned  into  the  abdomen. 

If  the  intestine  is  gangrenous,  an  artificial  anus  must  be 
formed,  and  it  is  well  to  stitch  the  bowel  fast  to  the  edges 
of  the  hernial  ring,  as  in  enterostomy.  If  the  gangrene 
extends  to  the  point  of  stricture  and  the  bowel  cannot  be 
drawn  further  out,  the  stricture  must  not  be  divided,  lest 


SPECIAL  OPERATIONS. 


431 


the  bowel  should  slip  back  and  feces  escape  into  the  peri- 
toneal cavity.  The  gangrenous  portion  must  be  incised, 
and  then,  if  the  feces  pass  freely,  nothing  more  need  be 
done,  beyond  taking  measures  to  prevent  the  bowel  from 
slipping  back,  such  as  making  its  edges  fast  to  the  sides  of 
the  incision,  or  passing  a  stout  ligature  through  the  mesen- 
tery and  fastening  it  to  the  skin  with  adhesive  plaster. 
But  if  the  stricture  still  prevents  the  flow  of  feces,  Gosse- 
lin's  plan  of  dilating  it  by  introducing  the  finger  into  the 
intestine  should  be  adopted. 

E.  Treatment  of  the  Omentum.  If  only  a  small  amount 
of  omentum  is  found  in  the  sac,  and  if  it  is  in  good  condi- 
tion, it  may  be  returned  ;  but  if  there  is  much  of  it,  or  if  it 


Fig.  228. 


Hernia.    The  relations  of  the  femoral  and  internal  abdominal  rings,  seen 
from  within  the  abdomen.    Right  side. 


is  inflamed,  suppurating,  or  gangrenous,  it  must  be  kept 
out  or  incised,  after  its  base  has  been  transfixed  in  one  or 
more  places  by  double  ligatures,  which  are  then  cut  apart 
and  tied. 


432 


OPERATIVE  SURGERY. 


Strangulated  Inguinal  Hernia.  Inguinal  hernia  may 
be  oblique  or  direct.  The  former  leaves  the  abdomen  at 
the  internal  (deep)  abdominal  ring,  having  the  deep  epigas- 
tric artery  on  the  inner  side  (Fig.  228),  passes  down  the 
iuguinal  canal,  and  emerges  at  the  external  abdominal  ring 
(Fig.  229) ;  the  latter  makes  its  way  through  Hesselbach's 


Epigastric  artery 


Inguinal  hernia,  showing  the  transversalis  muscle,  the  transversalis  fascia, 
and  the  internal  abdominal  ring. 


triangle,  a  space  bounded  by  the  epigastric  artery,  Poupart's 
ligament,  and  the  rectus  abdominis  muscle  (Fig.  228),  and 
also  emerges  at  the  external  abdominal  ring.  The  former 
is  by  far  the  more  common  variety. 

Operation.     The  parts  having   been  well    shaved  and 


SPECIAL  OPERATIONS.  433 

disinfected,  the  patient  is  anaesthetized  and  placed  upon 
his  back,  with  his  shoulders  slightly  raised.  The  sur- 
geon pinches  up  a  broad  fold  of  skin  and  subcutaneous 
tissue  across  the  long  axis  of  the  swelling,  transfixes  it 
at  its  base  with  a  straight  bistoury,  and  cuts  vertically 
through  it,  thus  dividing  most  of  the  tissues  without 
danger  of  injury  to  the  sac  or  intestine ;  if  necessary, 
this  incision  must  be  lengthened,  so  that  its  upper  ex- 
tremity will  lie  well  above  the  external  abdominal  ring, 
and  its  lower  extremity  below  the  bottom  of  the  hernial 
sac.  The  underlying  layers  are  then  pinched  up  one  by 
one  with  the  thumb  and  finger,  or  with  fine  forceps,  and 
divided  upon  a  director  until  the  sac  is  reached  and  opened, 
every  precaution  being  taken  to  avoid  injury  to  the  intes- 
tines. The  best  point  for  opening  it  is  at  its  extreme 
lower  end,  because  a  little  serum  is  usually  collected  there, 
separating  it  from  the  bowel.  It  must  be  pinched  up,  if 
possible,  at  the  point  selected,  and  an  opening  made  with 
the  knife  held  flat  against  it ;  a  director  or  the  finger  is 
then  passed  through  the  opening,  and  the  full  length  of 
the  sac  slit  up.  The  constriction  is  then  sought  for,  and, 
if  found  above  the  external  ring,  must  be  nicked  or  divided 
directly  upward,  or  cut  down  upon  from  without. 

If  it  can  be  positively  made  out  that  the  hernia  is  of  the 
oblique  variety,  the  cutting  should  be  doue  on  the  outer 
side,  for  the  epigastric  artery  lies  close  to  the  inner  side  of 
the  internal  ring,  through  which  this  variety  passes ;  and  if 
it  is  known  to  be  of  the  direct  variety,  the  cutting  must  be 
done  upon  the  inner  side.  But,  unfortunately,  in  most 
cases  the  dragging  of  the  hernia  brings  the  two  rings  im- 
mediately opposite  each  other,  so  that  the  inguinal  canal 
can  no  longer  be  said  to  exist,  and  the  diagnosis  cannot  be 
made  with  certainty.  The  incision  must  then  be  made 
upward,  parallel  to  the  course  of  the  epigastric  artery. 

The  intestine  must  next  be  examined  to  ascertain  if  it  is 
in  a  fit  condition  to  be  returned ;  and  here  it  must  not  be 
forgotten  to  draw  down  an  inch  or  more  of  each  end  so  that 
the  part  which  has  undergone  constriction  may  also  be  ex- 
amined. If  the  condition  is  satisfactory,  the  bowel  is  re- 
turned gradually,  not  en  masse,  and  the  wound  closed  by 
one  of  the  methods  about  to  be  described  for  radical  cure, 


434  OPERATIVE  SURGERY. 

preferably  Bassini's.     If  it  cannot  be  safely  returned,  it  is 
resected  or  fastened  in  the  wound,  as  in  enterostomy. 

Strangulated  Femoral  Hernia.  The  intestine  in  its 
descent  occupies  a  canal  which  begins  at  the  femoral  ring 
under  Poupart's  ligament,  between  the  free  arched  border 
of  Gimbernat's  ligament  and  the  femoral  vessels  (Fig. 
228),  and  ends  at  the  saphenous  opening  in  the  fascia 
lata  of  the  thigh.  After  passing  through  the  opening  it 
turns  upward  over  the  groin.  The  normal  length  of  the 
canal  is  about  an  inch,  but  in  hernias  of  long  standing  it 
is  much  shortened  by  the  approximation  of  its  two  ends. 
The  seat  of  stricture  is  now  thought  to  lie  in  most  cases 
at  the  saphenous  opening,  or  just  above  it,  and  not  at  the 
base  of  Gimbernat's  ligament,  as  was  formerly  supposed  ; 
free  division  is  possible  at  the  former  point  on  the  upper  and 
inner  side  without  the  risk  of  injury  to  any  organ,  except 
possibly  the  spermatic  cord,  aud  that  is  at  such  a  distance  as 
to  be  practically  out  of  harm's  way.  Under  ordinary  cir- 
cumstances, Gimbernat's  ligament  can  also  be  safely  divided 
on  the  inner  side,  but  in  about  one  and  one-half  per  cent,  of 
cases  the  obturator  artery  pursues  the  anomalous  course 
shown  in  Fig.  230,  and  then  lies  directly  in  the  way  of  the 

Fig.  230. 


(HI 

Variations  in  origin  and  course  of  obturator  artery. 

knife.  The  neck  of  the  sac  under  such  circumstances  is 
entirely  surrounded ;  on  its  outer  side  are  femoral  vessels, 
above  are  the  spermatic  cord  and  common  trunk  of  the 
epigastric  and  obturator  arteries,  on  its  inner  side  the  ob- 
turator artery,  below  it  the  bone.  The  only  safe  plan  of 
relieving  the   stricture,  therefore,  is  to  nick  it  slightly,  to 


SPECIAL  OPERATIONS.  435 

the  depth  of  one  or  two  millimetres,  at  several  points  on 
its  upper  and  inner  borders.  The  coverings  of  the  hernia 
are  thin  and  composed  of  the  skin,  subcutaneous  tissue, 
cribriform  fascia  sometimes,  septum  crurale,  and  perito- 
neum. 

The  incision  may  be  straight  or  curved,  the  convexity- 
directed  downward  and  outward,  or  T-shaped,  the  hori- 
zontal branch  being  made  along  Poupart's  ligament,  the 
other  passing  directly  downward  over  the  saphenous  open- 
ing, and  should  be  made  from  without  inward.  The 
single  vertical  incision  just  to  the  inner  side  of  the  femoral 
vessels  is  the  one  usually  employed.  The  underlying 
tissues  must  be  divided,  and  the  sac  exposed  or  opened  in 
the  manner  described  under  General  Directions,  and  the 
seat  of  stricture  sought  for  and  divided  according  to  the 
rules  above  laid  down. 

The  gut  is  then  pulled  down  and  examined,  and  if  its 
condition  is  satisfactory  it  is  returned  and  a  radical  cure 
performed.  If  not,  it  is  resected  or  fastened  in  the  wound. 
Femoral  epiplocele  is  treated  like  the  inguinal. 

Strangulated  Umbilical  Hernia.  It  is  generally  claimed 
that  true  umbilical  hernia,  that  is,  hernia  through  the  um- 
bilical ring,  is  almost  always  congenital,  and  that  the 
hernias  which  occur  during  adult  life  emerge,  not  through 
the  ring,  but  through  an  accidental  opening  in  the  linea 
alba  near  it,  and  therefore  deserve  the  name  of  peri-umbilical 
given  them  by  Gosseliu.  While  this  condition,  that  is,  of 
escape  through  a  chance  opening  in  the  linea  alba,  may  exist 
in  some  cases,  Richet1  has  sought  to  prove  by  anatomical 
considerations  and  by  the  results  of  the  examination  of 
three  cases  of  hernia,  that  true  umbilical  hernia,  on  the  con- 
trary, is  the  rule,  and  the  other  is  the  exception.  He  shows 
that  the  weak  point  of  the  ring  is  its  upper  portion,  and 
that  when  the  cicatrix  is  pressed  downward  and  given  a 
semicircular  form  by  the  hernia,  a  complete  ring,  which 
seems  to  be  situated  above  that  corresponding  to  the  vein 
and  arteries,  is  constituted  by  the  cicatrix  below  and  the 
upper  part  of  the  opening  above,  and  exactly  resembles  a 
distended  accidental  perforation. 

1  Anatoinie  Medico-Chirurgicale,  Part  II.  p.  37S. 


436  OPERATIVE  SURGERY. 

The  peritoneum  is  much  more  adherent  to  the  abdominal 
wall  in  the  umbilical  than  it  is  in  the  inguinal  region,  and, 
consequently,  the  sac  of  a  hernia,  being  formed  by  the  dis- 
tention of  a  small  portion  of  peritoneum,  is  exceedingly 
thin,  in  fact  its  existence  has  been  denied.  The  coverings 
of  the  hernia  are  the  skin,  cellular  tissue,  and  peritoneum ; 
its  contents  are  the  small  intestine,  sometimes  the  transverse 
colon,  and  in  the  adult  the  omentum. 

On  account  of  the  pathological  changes  which  take  place 
in  the  sac  and  its  contents,  it  is  best  to  undertake  a  formal 
laparotomy  if  the  hernia  is  strangulated  or  irreducible.  An 
incision  is  made  gently  curving  outward  around  one  side 
of  the  base  of  the  hernial  tumor,  and  prolonged  a  couple 
of  inches  above  and  below  it  in  the  median  line.  The  in- 
cision is  deepened  layer  by  layer  and  the  peritoneum  opened 
in  the  median  line  above  and  below  the  neck  of  the  hernial 
sac,  and  in  the  intermediate  space  divided  on  the  finger  as 
a  guide,  in  the  line  of  the  cutaneous  incision  close  outside 
the  neck  of  the  sac,  sparing  the  margin  of  the  rectus  mus- 
cle as  much  as  possible.  A  sponge  protective  packing  is 
placed  on  the  surrounding  viscera,  and  an  incision  is  made 
through  the  neck  and  body  of  the  sac,  including  the  over- 
lying skin,  at  right  angles  to  the  centre  of  the  curved 
incision  around  the  base  of  the  hernial  tumor,  exposing 
the  hernial  contents  without  damaging  them. 

The  constriction  is  thus  relieved,  and  the  dissection  is 
continued  till  the  hernial  contents  are  freed  from  adhesions 
to  each  other  and  the  sac.  If  they  consist  of  omentum 
alone,  the  excess  is  excised  on  the  proximal  side  of  the 
strangulation  and  the  abdominal  wound  treated  as  described 
below.  If  of  intestine,  the  gut  is  surrounded  by  warm 
cloths  or  placed  in  the  abdomen  on  the  sponge  protectives. 
Then  the  hernial  sac,  together  with  the  overlying  skin  and 
the  umbilicus,  is  excised  with  division  of  the  peritoneum 
close  around  the  neck  of  the  sac. 

The  intestine  is  next  inspected,  and  if  gangrene  is  present 
the  gut  is  resected  or  left  outside  the  partially  closed  ab- 
dominal wound  for  the  slough  to  separate.  A  couple  of 
Lembert  sutures,  or  a  stout  silk  loop  through  the  mes- 
entery, serve  to  retain  the  healthy  part  above  and  below  the 
damaged  area  in  the  margins  of  the  wound. 


SPECIAL  OPERATIONS.  437 

If  the  gut  is  healthy,  after  excision  of  the  excess  of 
omentum  and  of  the  sac  with  its  overlying  skin  and 
umbilicus,  the  sponge  protective  packiug  is  removed,  the 
edges  of  the  sheaths  of  the  recti  muscles  are  freshened,  and 
the  abdominal  wound  closed  in  the  usual  way  with  close 
approximation  of  the  recti.  The  wound  is  then  dressed  in 
the  ordinary  manner. 

Strangulated  Obturator  Hernia.  A  long  incision  is  made 
parallel  to  the  femoral  vessels  and  about  an  inch  away  from 
them  on  the  inner  side.  Tlie  pectineus  muscle  is  exposed 
and  divided,  as  are  also  any  fibres  of  the  obturator  externus 
whose  division  may  be  necessary  to  give  access  to  the  seat 
of  the  stricture.  The  relations  of  the  artery  and  nerve  to 
the  neck  of  the  sac  must  be  determined,  and  the  division 
made  in  such  a  direction  that  they  will  not  be  injured. 

If  the  gut  can  be  returned  into  the  abdomen  a  radical 
cure  can  then  be  attempted.  This  consists  simply  in  isola- 
tion of  the  sac,  its  ligation  as  high  as  possible  after  reduc- 
tion of  the  hernia,  excision  of  the  distal  portion,  closure  of 
the  orifice  with  silkworm-gut,  and  suture  of  the  wound  in 
the  overlying  soft  parts. 

The  same  may  be  said  of  hernia  occurring  in  such 
unusual  localities  as  Petit's  triangle,  the  great  sacrosciatic 
foramen,  etc. 

If  the  gut  is  gangrenous  it  must  be  fastened  in  the 
wound  as  in  enterostomy  or  resected,  provided  the  condition 
of  the  patient  permits. 


RADICAL    CURE    OF    INGUINAL    HERNIA. 

Czemy's  Operation}  An  incision  is  made  three  or  four 
inches  long  over  the  inguinal  canal  and  upper  end  of  the 
hernial  sac,  with  its  centre  opposite  the  external  abdominal 
ring.  The  aponeurosis  of  the  external  oblique  muscle  and 
the  sac  are  exposed,  and  the  neck  of  the  latter  dissected 
free  from  the  surrounding  parts.  This  is  most  easily  done 
after  the  body  of  the  sac  has  been  opened  and  the  hernial 

•  Wien.  med.  Woch.,  1877,  No.  21. 


438  OPERATIVE  SURGERY. 

contents  freed  from  adhesions  and  reduced,  and  one  finger 
passed  through  the  interior  of  the  neck  of  the  sac  to  make 
it  tense  and  serve  as  a  guide  in  the  dissection. 

The  neck  of  the  sac  is  drawn  down  and  tied  off  as  high 
up  as  possible  or  at  the  internal  abdominal  ring,  with  a 
stout  catgut  ligature,  which  is  drawn  tight  over  the  tip  of 
the  finger  placed  inside  the  neck  to  prevent  prolapse  of  the 
hernia  and  its  inclusion  in  the  ligature.  Czerny  drew  the 
serous  surface  together  by  a  continuous  (purse-string)  silk 
suture  passed  from  the  inside.  The  sac  distal  to  the  liga- 
ture is  excised,  though  any  part  or  the  whole  of  it  can  be 
left  undisturbed  if  it  seem  advisable. 

The  sides  of  the  opening  in  the  abdominal  wall  are 
drawn  together  with  catgut  or  silkworm-gut  sutures  passed 
through  all  the  layers  between  the  skin  and  peritoneum, 
and  closed  over  the  cord,  which  is  left  to  emerge  through 
as  small  an  opening  as  possible  at  the  lower  angle  of  the 
suture  line.  The  skin  wound  is  closed  with  interrupted 
fine  silk  sutures,  and  if  it  seem  necessary  a  strip  of  rubber 
tissue  is  placed  in  the  lower  angle  of  the  wound  for 
drainage. 

Ball1  applied  torsion  to  the  sac  and  its  neck  before  li- 
gating  and  excising  the  distal  portion.  Barker2  dissects 
out  and  divides  the  neck  of  the  sac,  transfixes  and  ties  it 
off  with  a  silk  ligature,  and  then  uses  the  long  ends  of  the 
latter  as  a  suture  to  close  the  internal  riug  and  overlying 
wound.  He  does  not  remove  the  body  of  the  sac.  The 
rest  of  the  wound  is  closed  by  both  as  in  Czerny's  opera- 
tion. Macewen3  dissects  out  the  sac,  its  neck,  and  the 
immediately  adjoining  peritoneum.  He  then  inverts  and 
reinverts  the  apex  of  the  sac  into  its  neck,  transfixes  and 
ties  together  with  a  firm  catgut  or  silk  ligature  the  mass 
thus  formed  and  fastens  it  on  the  inner  surface  of  the 
internal  abdominal  ring.  The  latter  is  closed  by  suturing 
the  conjoined  tendon  to  the  inner  surface  of  Poupart's 
ligament.  The  external  ring  is  narrowed  as  much  as  pos- 
sible by  silkworm-gut  stitches  and  the  cutaneous  wound 
united  over  it. 


1    Brit.  Mud.  Jour.,  1W7,  ii.  p.  1272. 
a  [bid.  p.  L208. 
::  Ibid.  p.  1268. 


SPECIAL  OPERATIONS.  439 

The  main  feature  of  the  last  three  operations  is  the 
attempt  to  obliterate  the  funnel-shaped  depression  leading 
into  the  neck  of  the  hernial  sac  and  to  substitute  at  this 
point  an  elevation. 

Kocher's1  method  has  yielded  excellent  results,  and  is  as 
follows  :  An  incision  three  or  four  inches  long  is  made  in 
the  long  axis  of  the  hernial  tumor ;  its  centre  is  over  the 
external  ring ;  ouly  the  skin  and  subcutaneous  tissue  are 
divided ;  none  of  the  external  oblique  muscle  is  cut. 
After  dissecting  out  the  body  and  neck  of  the  sac  up  to 
the  internal  abdominal  ring  and  reducing  the  hernia,  a 
finger  is  passed  up  the  inguinal  canal  and  on  its  tip  as  a 
director  an  artery  clamp  is  forced  through  the  external  and 
internal  oblique  and  transversalis  muscles  at  a  point  about 
half  an  inch  to  the  outer  side  of  the  internal  ring.  With- 
out removing  it  from  the  puncture  the  clamp  is  passed  on 
down  the  inguinal  canal  and  made  to  seize  the  apex  of  the 
sac,  which  is  then  drawn  up  and  pulled  through  the  punc- 
ture and  twisted  into  a  round  cord.  The  latter  is  laid  upon 
the  outer  surface  of  the  external  oblique  and  lower  down 
in  the  inguinal  canal  and  secured  there  by  five  or  six  su- 
tures passed  through  all  the  structures  (except  the  skin, 
subcutaneous  tissue,  and  peritoneum)  on  each  side  of  the 
inguinal  canal.  The  last  one  or  two  sutures  through  the 
extremity  of  the  twisted  sac  and  the  pillars  of  the  external 
ring  draw  the  latter  tog-ether.  The  cutaneous  wound  is 
then  closed  and  dressed  antiseptically. 

Bassini's  Operation.2  An  incision  three  or  four  inches 
long  is  made  from  the  level  of  the  upper  part  ot  the  inter- 
nal abdominal  ring  obliquely  downward  over  the  long  axis 
of  the  hernial  tumor.  The  aponeurosis  of  the  external 
oblique  muscle  is  exposed  and  divided  from  the  upper 
border  of  the  internal  abdominal  ring  over  the  whole  length 
of  the  inguinal  canal,  and  the  neck  of  the  hernial  sac  iso- 
lated from  the  cord  and  surrounding  parts.  (Fig.  231.) 
The  body  of  the  sac  is  nicked  and  opened  sufficiently  to 
free  its  contents  from  possible  adhesions,  and  to  permit 
reduction  of  the  hernia  by  a  finger   passed  through  the 

1  Annals  Surg.,  1892,  vol.  16,  p.  505. 

2  Centralb.  f.  Chir.,  1890,  vol.  40,  p.  429. 


440 


OPERATIVE  SURGERY. 


interior  of  the  neck  of  the  sac  to  its  abdominal  orifice. 
The  neck  is  then  drawn  down,  dissected  free^  and  encircled 
or  transfixed  as  high  up  as  possible  by  a  stout  catgut  lig- 
ature, which  is  drawn  tight  over  the  tip  of  the  finger  still 


Fig.  231. 


A,  A,  A.  Subcutaneous  cellular  tissue. 

E.  Spermatic  cord. 

B,  C.  Aponeurosis  of  external  oblique  divided  and  turned  back. 
Q.  Epigastric  vessels. 

F.  Internal  oblique  and  transversalis  muscles  and  vertical  fascia  of  Cooper. 


kept  inside  the  neck  of  the  sac  to  prevent  the  prolapse  of 
any  viscus  and  its  inclusion  in  the  ligature.  The  lower 
portion  of  the  sac  is  then  dissected  out  and  excised. 

The  margins  of  the  wound,  including  the  divided  apo- 
neurosis of  the  external  oblique  muscle,  arc  well  retracted, 
and  on  the  outer  side  of  the  internal  abdominal  ring  and 


SPECIAL  OPERATIONS. 


441 


inguinal  canal,  the  upper  border  of  Poupart's  ligament  is 
exposed,  and  on  the  inner  side  the  conjoined  edge  of  the 
internal  oblique  and  transversalis  muscles  and  the  trans- 
versalis  fascia.  After  raising  the  cord  these  structures  on 
the  inner  side  of  the  internal  abdominal  ring  and  inguinal 
canal  are  united  beneath  the  cord  to  Poupart's  ligament 

Fig.  232. 


Suture  of  the  conjoined  tendon  and  transversalis  fascia  (F)  to  the  posterior 
border  of  Poupart's  ligament  (D). 
E.  The  cord. 
B,  C.  Aponeurosis  of  the  external  oblique. 

by  interrupted  silkworm-gut  sutures  extending  upward 
from  the  crest  of  the  pubes  till  onty  enough  space  in  the 
upper  and  outer  part  of  the  internal  abdominal  ring  is 
left  for  the  cord  to  pass  without  undue  compression.  The 
lower  two  sutures  should  include  the  outer  border  of  the 
rectus  muscle.     (Fig.  232.) 


442 


OPERATIVE  SURGERY. 


The  cord  is  then  placed  on  this  new  posterior  wall  of  the 
inguinal  canal  and  the  divided  aponeurosis  of  the  external 
oblique  muscle  united  over  it  by  interrupted  silkworm-gut 
sutures,  leaving  as  small  an  aperture  as  possible  at  the 
lower  angle  for  the  cord  to  emerge.    (Fig.  233.)    The  skin 


Fig.  233. 


\  I 

Suture  of  the  divided   aponeurosis  of  the  external  oblique  (B,  C)  over   the 
spermatic  cord  (E). 

wound  is  sutured  with  interrupted  silk  and  dressed  anti- 
septically  without  drainage,  and  in  children  it  is  wise  to 
add  a  plaster-of-Paris  spica. 

Bassini  uses  silk  for  the  buried  sutures  and  forms  the 
new  internal  abdominal  ring  about  half  an  inch  to  the  inner 
side  of  the  anterior  superior  spine  of  the  ilium;  that  is,  he 
divides  the  internal  oblique  and  transversalis  muscles  above 
and  to  the  outer  side  of  the  internal  abdominal  ring,  trans- 


SPECIAL  OPERATIONS. 


443 


plants  the  cord  to  the  outer  extremity  of  this  incision, 
fastens  the  internal  oblique  aud  trausversalis  under  it  and 
the  external  oblique  over  it.  If  the  hernia  is  complicated 
by  undescended  testicle  Bassini  unfolds  the  vas  deferens  by 
a  careful  dissection  and  brings  the  testicle  down  from  the 
inguinal  canal  and  sutures  it  to  the  bottom  of  the  scrotum. 
If  this  is  impossible  castration  is  performed. 

Lauenstein  places  the  testicle  in  the  abdomen  along  with 
the  stump  of  the  sac.  In  congenital  hernia  enough  of  the 
fundus  of  the  sac  is  left  to  form  a  tunica  vaginalis. 


Fig.  234. 


Fig.  235. 


Fig.  236. 


Method  of  tying  off  omentum  in  sections. 

In  direct  inguinal  hernia  the  orifice  of  the  hernia 
is  formed  by  the  external  abdominal  ring,  the  neck  of  the  sac 
is  short  and  passes  over  the  cord  and  lies  to  the  inner 
side  of  the  deep  epigastric  artery.  As  the  hernia  in- 
creases in  size  the  neck  of  the  sac  comes  to  overlap  the 
artery,  aud  thus  in  time  may  pass  on  both  sides  of  it  and 
contain  the  artery.  After  tying  off  the  neck  of  the  sac 
of  a  direct  inguinal  hernia,  the  parts  on  the  inner  side  of 
the  abdominal  orifice,  between  the  peritoneum  and  external 
oblique  tendon,  are  sutured,  as  in  the  indirect  variety,  to 
Poupart's  ligament. 


444  OPERATIVE  SURGERY. 

If  the  hernia  is  an  epiplocele  the  excess  of  omentum  is 
tied  off  with  stout  catgut  close  to  the  neck  of  the  sac  aud 
excised.  If  it  is  very  large,  the  pedicle  should  be  spread 
out  and  tied  in  sections,  as  illustrated  in  Figs.  234,  235, 
236. 

Halsted's  operation1  is  as  follows  :  The  aponeurosis  of 
the  external  oblique  and  the  external  abdominal  ring  are 
exposed  by  an  incision  starting  some  5  centimetres  above 
and  external  to  the  internal  ring  and  extending  to  the 
spine  of  the  pubes.  In  this  line  the  aponeurosis  of  the  exter- 
nal oblique  and  the  fibres  of  the  internal  oblique  and  trans- 
versalis  muscles  and  the  transversalis  fascia  are  cut  from  the 
external  ring  to  a  poiut  about  2  centimetres  above  and  ex- 
ternal to  the  internal  ring.  The  peritoneum  and  neck  of 
sac  are  thus  exposed,  the  latter  opened,  the  hernia  reduced, 
and  the  neck  of  the  sac  ligated  or  sutured  and  the  distal 
portion  excised.  The  cord  is  then  isolated,  and,  after  remov- 
ing all  but  one  or  two  of  its  veins,  it  is  transplanted  to  the 
outer  angle  of  the  incision.  Beneath  it  mattress  sutures 
are  passed  :  on  the  inner  side  through  the  aponeurosis  of 
the  external  oblique,  the  internal  oblique  and  transversalis 
muscles,  and  transversalis  fascia ;  on  the  outer  side  through 
the  aponeurosis  of  the  external  oblique,  Poupart's  ligament, 
and  the  transversalis  fascia.  This  obliterates  the  canal  and 
places  the  cord  on  the  outer  surface  of  the  external  oblique 
aponeurosis,  where  it  is  covered  by  skin  and  subcutaneous 
tissue  only.  The  cutaneous  wound  is  then  closed  by  super- 
ficial sutures  and  dressed  antiseptically  without  drainage. 


m'burney's  operation.2. 

The  incision,  division  of  the  aponeurosis  of  the  external 
oblique  muscle,  and  the  treatment  of  the  sac  are  the  same 
as  in  Bassini's  operation. 

Sutures  are  then  passed  through  the  skin,  the  aponeurosis 
of  the  external  oblique  (including  the  inner  pillar  of  the 
external    ring),  and   the  conjoined   tendon  firmly  binding 

i  Annals  of  Surgery,  1803,  vol   17,  p.  542. 

2  New  York  Medical  Record,  1889,  vol.  35,  p.  312. 


SPECIAL  OPERATIONS.  445 

these  structures  together  with  deep  inversion  of  the  skin. 
Od  the  opposite  side  of  the  wound  the  skiu  is  inverted 
and  sutured  to  Poupart's  ligament,  including  at  the  lower 
part  the  outer  pillar  of  the  external  ring ;  the  lower  angle 
of  the  wound  is  sutured  with  silk  over  the  cord  and  drawn 
together  above  with  two  or  more  tension  sutures  passed 
through  the  skin  and  superficial  fascia  and  tied  over 
pledgets  of  iodoform  gauze.  The  space  of  about  one-fifth 
of  an  inch  left  between  the  lips  of  the  wound  is  packed 
snugly  with  iodoform  gauze  down  to  the  peritoneum  to  in- 
sure healing  by  granulation  and  the  obliteration  of  the 
inguinal  canal  by  dense  cicatricial  tissue.  This  operation 
was  at  first  extensively  used,  but  of  late  has  largely  yielded 
place  to  Bassini's ;  it  is,  however,  a  safer  and  surer  opera- 
tion for  the  less  experienced. 

Radical  (Jure  of  Umbilical  Hernia.  If  the  hernia  is 
irreducible,  the  treatment  is  the  same  as  that  described  for 
strangulated  umbilical  hernia. 

If  reducible,  an  incision  is  made  which  encircles  the  base 
of  the  hernial  tumor,  extending  an  inch  or  two  above  and 
below  it  in  the  median  line,  and  deepened  layer  by  layer 
till  the  abdominal  cavity  is  opened  at  one  extremity  of  the 
incision.  A  flat  sponge  is  inserted,  and  on  the  finger  as  a 
guide  the  peritoneum  is  divided  in  the  line  of  the  cuta- 
neous incision  around  the  neck  of  the  sac,  and  the  latter 
excised  together  with  the  body  of  the  sac,  the  overlying 
skin,  and  the  umbilicus.  The  peritoneum  is  then  sutured 
with  catgut,  the  sponge  being  removed  before  the  last  stitch 
is  tied  ;  the  edges  of  the  sheaths  of  the  separated  recti 
muscles  are  freshened  throughout  the  whole  length  of  the 
wound,  and  the  recti  closely  approximated  with  interrupted 
catgut  or  silkworm-gut  sutures.  Over  this  the  super- 
ficial fascia  and  skiu  are  united  with  silk  after  excision  of 
any  redundant  portions. 

Radical  Cure  of  Femoral  Hernia.  Starting  from  Pou- 
part's ligament  a  vertical  incision  some  three  or  four  inches 
long  is  made  just  to  the  inner  side  of  the  femoral  vessels. 
It  must  be  deepened  carefully,  as  the  coverings  of  the 
hernia  may  be  very  thin  and  consist  only  of  skin  and  super- 
ficial fascia  if  the  hernia  has  passed  through  the  cribriform 

20 


446  OPERATIVE  SURGERY. 

fascia.  After  exposing  and  opening  the  sac  and  returning 
the  bowel  or  possibly  excising  the  omentum,  the  neck  of 
the  sac  is  isolated  and  tied  off  high  up  with  silk  or  stout 
catgut. 

Various  procedures  have  been  adopted  for  the  succeed- 
ing steps  in  the  operation.  Billroth  removed  the  portion 
of  the  sac  distal  to  the  ligature  and  sutured  the  middle 
third  of  Pou part's  ligament  to  the  fascia  covering  the  ab- 
ductor muscles,  or  to  that  on  the  inner  aspect  of  the  femoral 
vessels.  Berger  united  Poupart's  ligament  to  the  pubic  por- 
tion of  the  fascia  lata  covering  the  pectineus  muscle.  A 
flap  cut  from  the  latter  muscle  has  been  turned  up  and 
fastened  in  the  femoral  ring. 

Macewen  employs  the  same  principle  as  for  the  cure  of 
inguinal  hernia  (q.  v.) ;  i.  e.,  the  sac  is  folded  into  a  pad  and 
secured  on  the  inner  surface  of  the  femoral  ring,  which  is 
then  drawn  together  with  silk  or  silkworm-gut  passed 
through  the  available  soft  parts  adjoining  its  boundaries. 
Kocher  exposes  the  sac  and  saphenous  opening  by  a  ver- 
tical incision,  but  does  not  divide  the  fascia  lata  overlying  the 
canal ;  the  sac  is  then  drawn  through  a  puncture  in  Pou- 
part's ligament  just  over  the  canal,  twisted,  and  its  extremity 
brought  down  over  the  ligament  into  the  canal  again,  and 
secured  there  by  two  or  three  silk  sutures  passed  through 
it  and  Poupart's  ligament  and  the  pectineal  fascia. 

After  obliterating  the  track  of  the  hernia  by  whatever 
method  is  adopted,  the  external  wound  is  closed  and 
dressed  antiseptically. 


EECTUM. 

Anatomy.  The  rectum  is  from  six  to  eight  inches  long, 
and  for  about  its  first  three  inches  is  covered  by  peritoneum 
and  supplied  with  a  mesorectum.  In  front  the  peritoneum 
descends  to  within  about  three  inches,  and  behind  about 
five  inches  from  the  anus.  The  second  portion  of  the  rec- 
tum is  in  relation  in  front,  in  the  male,  with  the  trigonum 
of  the  bladder,  the  vesiculae  scminalcs,  and  the  vasa  defer- 
entia  and  the  prostate,  the  posterior  margin  of  which  can 
normally   be  reached   by  the  finger.     In   the   female  this 


SPECIAL  OPERATIONS.  447 

portion  of  the  rectum  is  attached  to  the  posterior  vaginal 
wall. 

Below  the  prostate  the  levatores  ani  joiu  the  rectum 
from  one  aud  a  half  to  two  iuches  from  the  anus,  at  a  point 
just  above  the  internal  sphincter.  The  superior  hemor- 
rhoidal artery  lies  on  the  outer  surface  of  the  rectum  be- 
hind, a  little  to  the  left  of  the  middle  line,  till  within 
about  four  inches  of  the  anus.  It  then  divides  into  its 
terminal  branches,  which  have  a  longitudinal  distribution 
between  the  mucous  and  muscular  coats  and  communicate 
freely  about  the  anus. 

The  veins  have  a  similar  distribution,  and  communicate 
through  the  superior  hemorrhoidal  with  the  portal  system, 
and  through  the  middle  and  inferior  hemorrhoidal  with 
the  internal  iliac  veins.  The  sphincter  is  supplied  by  the 
fourth  sacral  nerve. 


IMPERFORATE    ANUS    OR    RECTUM. 

In  order  to  understand  their  different  congenital  deform- 
ities, it  is  essential  to  bear  in  mind  the  manner  in  which  the 
rectum  and  anus  are  developed.  The  rectum,  like  the  rest 
of  the  intestine,  is  formed  by  the  third  blastodermic  layer 
of  the  ovule,  aud  originally  communicates  with  the  pedicle 
of  the  allantoid  vesicle,  that  which  afterward  becomes  the 
bladder  and  the  posterior  portion  of  the  urethra.  The 
anus,  on  the  other  hand,  is  formed  by  a  dimple  in  the  outer 
blastodermic  layer,  the  one  which  forms  the  epidermis.  In 
the  ordinary  course  of  events  the  communication  between 
the  rectum  and  the  bladder  or  urethra  closes,  and  another 
forms  between  the  rectum  and  anus  by  absorption  of  the 
layer  of  tissue  between  them.  The  malformations  are  the 
result  of  arrest  of  development  of  the  colou,  rectum,  or 
anus,  or  of  the  persistence  of  the  septum,  and  present 
several  varieties. 

The  first,  and  slightest,  is  not  a  true  arrest  of  develop- 
ment, but  a  simple  closure  of  the  orifice  of  the  anus  by  a 
tegumentary  layer  or  by  adhesion  of  its  sides,  the  deep  com- 
munication   between  it  and  the    rectum  being   complete. 


448  OPERATIVE  SURGERY. 

This  requires  only  separation  of  the  adherent  edges  with  a 
director,  or  division  of  the  layer  with  a  knife. 

2.  The  rectum  and  anus  maybe  fully  developed,  but  the 
thin  membranous  diaphragm  between  them  may  persist, 
like  the  hymen  in  the  vagina.  The  treatment  of  this  also 
is  simple  :  crucial  incision  or  large  puncture  of  the  mem- 
brane. 

3.  The  anus  may  be  entirely  absent,  while  the  rectum  is 
normally  developed ;  the  distance  between  the  lower  end  of 
the  latter  and  the  surface  being  from  half  an  inch  to  an 
inch. 

4.  The  anal  cul-de-sac  being  properly  developed,  the 
rectum  or  colon  may  terminate  at  any  distance  above  it,  or 
may  even  not  exist  at  all,  being  represented  by  a  fibrous 
cord  extending  from  the  ileo-csecal  valve  to  the  anus. 

5.  The  arrest  of  development  may  involve  both  the  anus 
and  the  rectum. 

6.  The  rectum  may  open  into  the  bladder,  urethra,  or 
vagina. 

It  is  often  exceedingly  difficult  to  determine  the  character 
of  the  malformation  during  life,  and  yet  it  is  very  important 
that  this  should  be  done,  for  if  the  imperviousness  begins 
at  a  point  too  high  up  to  be  reached  through  the  perineum, 
the  only  possibility  of  relief  is  in  the  establishment  of  an 
artificial  anus  in  the  lumbar  or  inguinal  region.  Depaul1 
says  that  when  the  obstruction  begins  at  the  ileo-csecal 
valve  the  transverse  distention  of  the  abdomen  is  much 
less  than  in  rectal  obstruction. 

If  the  surgeon  decides  to  go  in  search  of  the  blind  end 
of  the  rectum  and  create  an  anus  in  the  perineum,  he  must 
make  an  incision  in  the  median  line  from  the  scrotum  to 
the  tip  of  the  coccyx,  after  having  previously  introduced  a 
sound  into  the  bladder  if  the  patient  is  a  boy,  or  into  the 
vagina  if  a  girl.  He  then  divides  the  tissues  layer  by  layer 
in  the  line  of  the  incision,  feeling  at  each  step  for  the  dis- 
tended rectum,  which  can  sometimes  be  seen  and  felt  to 
bulge  downward  when  the  child  strains  or  cries.  Or  an 
exploratory  puncture  may  be  made,  and  the  needle  or  trocar 
used  as  a  guide  if  the  bowel  is  reached  by  it. 

i  Bull,  de  la  Soci6t6  de  Chirurgie,  1877,  p.  536. 


SPECIAL  OPERATIONS.  449 

The  search  for  the  bowel  should  be  made  in  the  direc- 
tion of  the  axis  of  the  anal  cul-de-sac,  if  the  latter  is  suffi- 
ciently developed,  and  advantage  taken  of  the  fact  pointed 
out  by  M.  Forget,1  that  a  fibrous  cord,  representing  a  rudi- 
mentary portion  of  the  rectum,  occupies  more  or  less  of 
the  distance  separating  the  two.  If,  on  the  contrary,  the 
anus  is  lacking,  the  search  must  be  made  toward  the  con- 
cavity of  the  sacrum.  Verneuil  has  proposed  to  excise 
the  coccyx,  so  as  to  diminish  the  danger  incurred  during 
the  search,  but  as  this  is  followed  by  prolapse  of  the  rectum 
it  should  be  practised  only  when  a  simple  incision  has  proved 
insufficient. 

When  the  end  of  the  bowel  is  reached  it  must  be  seized 
with  pronged  forceps,  or  two  stout  ligatures  must  be  passed 
through  it,  and  it  must  be  partly  separated  from  the  ad- 
joining tissues,  drawn  down,  opened,  and  made  fast  to  the 
integument  or  the  margin  of  the  anus.  The  anterior  and 
posterior  portions  of  the  cutaneous  incision  must  finally  be 
closed  by  sutures.  It  would  be  perfectly  proper  when  in 
doubt  as  to  the  presence  or  position  of  the  rectum  to  open 
the  abdomen  in  the  median  line  or  the  left  inguinal  region, 
and  then,  after  ascertaining  the  conditions,  if  necessary  per- 
form a  colotomy. 

When  the  rectum  opens  into  the  vagina  it  may  be 
reached  through  a  longitudinal  or  crucial  incision  in  the 
perineum,  separated  from  the  vaginal  wall  with  a  knife  or 
curved  scissors,  and  drawn  down  and  fastened  as  before. 
The  former  opening  will  then  close  spontaneously. 


PROLAPSE    OF   THE    RECTUM. 

The  mucous  membrane  of  the  rectum  is  very  loosely 
attached  to  the  muscular  coat,  and  when  the  sphincter  is 
relaxed  or  disabled  prolapse  may  occur  to  a  degree  that 
requires  operative  interference.  This  interference  may  in- 
volve the  mucous  membrane  alone,  or  it  may  also  include 
the  anus  or  the  entire  rectum.  In  the  first  case  the  indica- 
tion is  to  promote  adhesions  between  the  mucous  and  mus- 

1  Buil.  de  la  Societe  de  Chirurgie,  1863  and  1877. 


450  OPERATIVE  SURGERY. 

cular  coats,  or  to  remove  portions  that  may  be  in  excess ; 
in  the  second  to  narrow  the  anal  orifice.  The  former  is 
accomplished  by  making  deep  longitudinal  incisions  through 
the  mucous  membrane,  or  by  pinchiug  up  folds  at  three  or 
four  different  points  and  tying  a  strong  ligature  about  each. 
The  incisions  are  likely  to  give  rise  to  severe  hemorrhage, 
and  consequently  the  method  has  falleu  into  disuse;  the 
actual  cautery,  however,  applied  at  points  or  iu  lines,  has 
been  used  as  a  substitute  as  follows : 

In  a  slight  or  partial  prolapse  the  bowels  are  emptied  in 
advance  and  the  parts  reduced  and  put  on  the  stretch  with 
the  bivalve  speculum.  The  poiut  of  a  Paquelin  cautery 
is  drawn  the  whole  length  of  the  prolapse  in  four  longi- 
tudinal lines  about  a  quarter  of  an  inch  wide  and  equally 
distaut  from  each  other,  without  destroying  the  entire  thick- 
ness of  the  mucous  membrane.  To  avoid  penetrating  two 
deeply  Cripps  advises  that  the  cautery  be  used  at  a  black  heat 
only.  If  the  skin  about  the  anus  is  not  touched  the  after- 
pain  is  slight.  A  tube  reaching  above  the  sphincter  is  in- 
serted to  give  exit  to  flatus,  while  the  bowels  are  kept  con- 
fined for  several  days.  For  several  weeks  thereafter  the 
patient  must  defecate  iu  the  recumbent  positiou  and  avoid 
straining  efforts,  while  the  adhesions  caused  by  the  cauteri- 
zation become  firm  between  the  mucous  and  muscular  coats. 

There  are  two  methods  of  narrowing  the  anal  orifice. 
Dupuytren  pinched  up  with  forceps  several  of  the  radiating 
folds  of  integument  and  cut  them  off  with  curved  scissors, 
trusting  to  cicatricial  retraction  for  the  narrowing  he  de- 
sired. 

Robert  made  two  incisions,  extending  from  the  extremi- 
ties of  the  transverse  diameter  of  the  anus  to  the  tip  of  the 
coccyx,  removed  the  skin,  subcutaneous  tissue,  and  portion 
of  the  sphincter  contained  within  the  V  thus  marked  out, 
and  brought  the  sides  of  the  gap  together  with  sutures. 

Rectopexy.  In  cases  of  extensive  prolapse  the  rectum 
has  been  returned  into  the  abdomen  and  secured  in  the 
concavity  of  the  sacrum  behind  or  to  the  abdominal  wall 
in  (rout  or  in  the  left  inguinal  region. 

For  the  first  procedure  an  incision  is  made  in  the  median 
line  from  just  behind  the  anus  to  the  tip  of  the  coccyx,  and 
deepened  backward  and  upward  till  the  concavity  of  the 


SPECIAL  OPERATIONS.  451 

sacrum  is  reached.  A  catgut  suture  is  then  passed  through 
the  fibrous  tissue  in  front  of  this  bone,  and  through  the 
back  of  the  rectum  without  entering  its  lumen,  and  the 
wound  either  closed  immediately  or  after  two  or  three  days, 
during  which  it  is  lightly  packed. 

To  secure  the  rectum  to  the  anterior  abdominal  wall,  the 
peritoneal  cavity  is  opened  in  the  median  line  just  above 
the  pubes  with  every  antiseptic  precaution,  and  the  gut 
secured  at  the  peritoneal  aspect  of  the  wound,  as  in  hyster- 
opexy, by  a  silk  suture  passed  through  the  whole  thick- 
ness of  the  abdominal  wall,  and  the  anterior  longitudinal 
band  of  muscular  fibres  in  the  rectum.  The  lumen  of  the 
latter,  of  course,  must  not  be  entered. 

In  the  left  inguinal  region  the  abdomen  is  opened  as  for 
colotomy,  and  the  upper  end  of  the  rectum  fastened  to  the 
inner  surface  of  the  wound  in  a  similar  manner,  or  by  a 
suture  passed  through  the  whole  thickness  of  the  mesorec- 
tum  and  parietal  peritoneum.1 

Ablation.  For  pronounced  cases  with  gangrene  present 
or  threatening  Treves2  divides  the  rectum  circularly  layer 
by  layer  at  the  muco- cutaneous  junction,  taking  care  to 
avoid  injury  to  any  small  intestine  which  may  have  become 
herniated  into  the  pouch  formed  by  the  prolapse.  The  cut 
edges  of  the  skin  and  intestinal  mucous  membrane  are  then 
united  with  catgut.  If  the  peritoneum  is  opened  the  wound 
must  be  immediately  closed  with  Lembert  sutures. 

Torsion.  When  the  sphincter  has  been  destroyed  or 
removed  Gerster3  supplies  a  substitute  by  twisting  the  rec- 
tum on  its  long  axis  till  its  walls  form  a  rather  close  spiral. 
After  isolating  some  two  to  five  inches  of  its  lower  end 
the  gut  is  turned  through  about  half  a  circle  or  more,  and 
its  free  extremity  sutured  to  the  margin  of  the  skin. 

Rectotomy.  There  is  occasionally  found,  especially  in 
women,  a  form  of  stricture  occupyiug  the  lumen  of  the 
rectum  like  a  thin  perforated  diaphragm,  which  is  probably 

1  Berg.  Annals  Surg.,  1893,  vol.  xvii.  p.  37?!. 

2  Lancet,  1890,  vol.  i.  p.  376. 

3  Annals  Surg.,  1894,  vol.  xix.  p.  612. 


452  OPERATIVE  SUBGEBY. 

the  result  of  a  partial  persistence  of  the  foetal  membrane 
between  the  anal  portion  which  is  developed  from  below 
upward  by  the  dimpling  of  the  skin,  and  the  rectal  portion 
which  comes  down  from  above  to  meet  it.  For  the  treat- 
ment of  this,  after  emptying  the  bowels,  the  sphincter  is 
first  very  thoroughly  dilated  and  then  a  blunt  director  is 
forced  through  the  wall  of  the  rectum  in  the  posterior 
median  line  below  the  stricture  and  brought  back  into  the 
rectum  in  the  same  line  above  it.  By  hooking  the  finger 
or  a  loop  of  stout  wire  over  the  point  of  the  director  the 
stricture  can  be  drawn  down  within  reach  from  the  anus 
and  divided  layer  by  layer,  and  all  bleeding  points  secured 
with  ligatures.  A  drainage  tube  and  light  packing  are  passed 
through  the  anus  to  the  point  of  division. 

Strictures  more  extensive  than  these,  yet  not  suitable  for 
excision,  are  divided  with  the  kuife  or  cautery  in  the  median 
line  posteriorly  carrying  the  division  through  the  rectal 
wall  below  the  stricture,  and  the  sphincter  toward  the 
coccyx,  to  secure  the  most  perfect  drainage  possible.  A 
tube  and  packing  are  placed  in  the  incision. 


FISTULA. 

After  thoroughly  dilating  the  sphincter  a  blunt  director 
is  passed  from  without  till  its  point  is  felt  within  the  rec- 
tum, or  if  no  aperture  exists  it  is  thrust  through  the  mu- 
cous membrane  where  the  least  tissue  intervenes. 

The  point  is  then  pulled  down  out  of  the  rectum,  or,  if 
this  is  impossible,  the  anus  is  held  open  with  a  speculum, 
and  the  parts  on  the  director  divided  at  right  angles  to  the 
anal  margin.  If  there  is  no  external  orifice,  the  director  is 
bent  to  a  sharp  angle  and  passed  with  the  assistance  of  the 
speculum  from  the  internal  opening,  the  skin  incised  on  its 
point  and  the  parts  on  the  director  cut  as  before.  Sinuses 
in  all  directions  must  be  slit  up  and  granulations  scraped 
away.  Multiple  fistnhe  should  be  opened  into  each  other 
if  possible,  and  if  more  than  a  single  complete  division  of 
the  sphincter  is  necessary  one  division  should  be  allowed 
to  lical  before  the  next  is  made.  In  women  the  sphincter 
decussates  in  front  with  the  sphincter  vaginae  and  cannot 


SPECIAL  OPERATIONS.  453 

be  completely  divided  at  this  point  without  considerable 
loss  of  power. 

HEMORRHOIDS. 

Ligation.  Concerning  the  treatment  of  hemorrhoids  by 
ligation  there  are  a  few  points  which  deserve  mention.  The 
sphincter  should  be  temporarily  paralyzed  by  forcible  dila- 
tation. Every  pile  that  is  more  than  half  an  inch  in 
diameter  must  be  transfixed  by  a  needle  carrying  a  double 
ligature,  and  then  strangulated  by  tying  it  at  its  base;  the 
smaller  piles  do  not  need  to  be  transfixed,  it  is  sufficient  to 
throw  a  single  ligature  about  each.  When  the  tegumentary 
margin  is  to  be  included  in  the  ligature  it  should  be 
cut  through  it  with  scissors.  The  ends  of  the  ligatures 
should  not  be  cut  off  as  soon  as  they  are  tied,  but  after  three 
or  four  have  been  placed  at  opposite  points  of  the  circum- 
ference, it  will  be  found  easy  to  get  an  excellent  view  of 
the  interior  by  drawing  them  outward  and  apart.  The  tem- 
porary paralysis  of  the  sphincter  not  only  facilitates  the 
examination  and  operation,  but  it  spares  the  patient  pain 
during  convalescence. 

Whitehead's  Operation.1  The  sphincter  is  well  dilated, 
and  the  mucous  membrane  starting  posteriorly  is  divided 
at  its  junction  with  the  skin  by  blunt-pointed  scissors  around 
the  entire  circumference  of  the  bowel.  It  is  dissected  up 
with  the  dilated  veins  to  the  internal  sphincter,  or  till  all 
the  pile-bearing  mucous  membrane  is  drawn  outside  of  the 
anus.  The  mucous  membrane  is  then  divided  transversely 
by  short  snips  of  the  scissors  close  to  its  still  attached  upper 
border,  and  each  part  as  it  is  cut  sutured  to  the  edge  of  the 
skin.     The  vessels  are  secured  as  they  are  divided. 

EXCISION    OF    THE    ANUS   AND    PART   OF   THE    RECTUM. 

This  operation  may  be  rendered  necessary  by  disease 
otherwise  incurable.  The  resulting  condition  is  seldom  satis- 
factory, owing  to  the  loss  of  the  sphincter  if  the  anus  is 

»  British  Medical  Journal,  1887,  vol.  i.  p.  -M9. 
20* 


454  OPERATIVE  SURGERY. 

excised,  and  its  almost  certain  paralysis  from  injury  to  the 
nerves  during  the  manipulation,  if  the  anus  is  left.  It 
must  be  remembered  that  the  peritoneum  descends  upon 
the  anterior  surface  of  the  rectum  to  within  about  an  inch 
of  the  prostate,  but  not  quite  so  far  upon  the  sides  or  be- 
hind ;  its  average  distance  from  the  anus  is  from  two  to 
two  and  one-half  inches  in  front  and  five  inches  behind. 
If  the  upper  limit  of  the  tumor  on  the  posterior  side  can- 
not be  reached  by  the  end  of  the  finger  introduced  through 
the  anus,  its  removal  should  not  be  attempted  from  below. 
The  nature  and  extent  of  its  connections  with  the  impor- 
tant organs  on  the  anterior  surface  must  also,  of  course,  be 
carefully  determined. 

A.  Removal  from  below  of  the  Anus  and  Part  of  the 
Rectum.  Two  curved  incisions,  meeting  in  front  and  be- 
hind in  the  median  line,  are  made  through  the  skin,  one  on 
each  side  of  the  anus,  and  at  a  distance  of  about  one  inch 
from  it.  They  are  carried  down  to  the  rectum,  remaining, 
of  course,  external  to  the  neoplasm  if  it  has  broken  through 
the  rectal  wall,  and  the  rectum  is  then  dissected  upward  as  far 
as  necessary,  using  the  fingers  instead  of  the  knife  for  this 
purpose  whenever  possible.  A  sound  should  be  introduced 
into  the  bladder  as  a  guide  if  the  patient  is  a  man,  and  a 
finger  into  the  vagina  if  the  patieut  is  a  woman.  When 
the  upper  limit  of  the  tumor  is  reached,  the  rectum  is 
drawn  well  down,  its  posterior  wall  divided  longitudinally, 
and  the  diseased  portion  removed. 

If  the  disease  extends  upward  more  than  one  and  a  half 
inches,  it  is  advisable  to  prolong  the  incision  backward  to 
the  tip  of  the  coccyx,  and  perhaps  even  along  the  side  of 
this  bone. 

Velpeau  took  the  precaution  to  pass  a  number  of  threads 
through  the  intestine  above  the  proposed  line  of  excision, 
bringing  them  out  through  the  skin  beyond  the  external 
limits  of  the  disease.  After  the  removal  of  the  tumor,  he 
had  only  to  tighten  and  tie  these  threads  to  bring  the  edges 
of  the  incisions  through  the  intestine  and  the  skin  together. 

Richard  Volkmann1  has  modified  this  operation  somewhat 

1  (Jeber  den  Mastdarmkrebs  und  'lie  Exstlrpatio  recti  in  Kliuischer  Viirtrage, 
No.  131  (Chirurgie,  No.  42),  p.  1113, 13th  March,  1878. 


SPECIAL  OPERATIONS.  455 

and  claims  that  by  thorough  drainage  and  the  strictest 
attention  to  disinfection  of  the  wound  during  and  after  the 
operation,  excision  of  the  rectum  can  be  carried  to  a  very 
considerable  height,  and  even  the  peritoneal  cavity  opened, 
without  danger  to  the  patient.  He  empties  the  bowel 
thoroughly,  makes  a  circular  incision  about  the  anus,  a 
straight  one  in  the  median  line  back  from  the  circular  one 
to  the  coccyx,  and,  if  necessary,  another  in  the  median  line 
of  the  perineum  ;  the  bowel  itself  must  not  be  cut  into. 
He  then  draws  the  rectum  down,  dissects  it  out  circularly 
to  the  necessary  height,  passes  ligatures  through  the  healthy 
portion  after  Velpeau's  plan,  and  cuts  off  the  lower  portion 
containing  the  tumor.  Bleeding  points  are  temporarily  se- 
cured by  self-retaining  forceps,  and  afterward  with  catgut. 

If  the  peritoneal  cavity  is  opened,  a  sponge  soaked  in  a 
salicylic  acid  or  thymol  solution  is  kept  pressed  against  the 
opening,  until  the  excision  is  completed  ;  then  if  the  open- 
ing is  small  its  edges  are  drawn  out  with  artery  forceps,  and 
a  ligature  thrown  around  it  as  if  it  was  a  vessel ;  if  it  is 
large,  it  is  closed  with  catgut  sutures. 

The  upper  end  of  the  gut  is  then  drawn  down  and  fast- 
ened to  the  skin  very  accurately  with  alternate  deep  and 
superficial  sutures,  two  or  three  drainage  tubes  are  inserted, 
cut  off  close  to  the  surface,  and  stitched  fast. 

During  the  operation,  the  bleeding  surface  is  constantly 
protected  against  infection  by  irrigation  with  an  antiseptic 
solution,  and  for  the  first  three  or  four  days  constant  anti- 
septic irrigation  is  kept  up  through  a  tube  passed  well  into 
the  wound  near  one  of  the  drainage  tubes ;  daily  antiseptic 
injections  are  afterward  made  through  the  drainage  tubes 
until  the  wound  has  healed. 

Volkmann  claims  that  these  precautious  strictly  carried 
out  insure  the  patient  against  the  chief  danger  of  the  ope- 
ration, that  of  exciting  diffuse  pelvic  cellular  inflammation, 
which  spreads  rapidly  upward  behind  the  peritoneum,  and 
causes  death  by  septic  peritonitis.  Although  the  bleeding 
during  the  operation  is  very  severe,  he  has  never  known  it 
to  have  fatal  consequences. 

He  thinks,  also,  that  cancer  is  much  less  likely  to  return 
locally  after  excision  of  the  anus  than  it  is  when  the  sphinc- 
ters are  preserved,  aud,  therefore,  he  prefers  total  excision 


456  OPERA TIVE  S UB GEE  Y. 

of  the  anus  and  of  the  rectum  to  the  upper  limit  of  the 
disease,  even  when  the  anus  itself  is  not  involved. 

I  must  add  that  the  best  result  in  my  experience  or  ob- 
servation freedom  from  recurrence  that  has  now  lasted  for 
seven  years,  followed  removal  of  the  tumor  alone,  a  mass 
two  and  a  half  inches  in  diameter  on  the  posterior  wall  of 
the  rectum,  and  beginning  one  and  a  half  inches  above  the 
anus.  After  dilatation  of  the  sphincter  I  made  an  incision 
through  it  in  the  posterior  median  line  up  to  the  tumor, 
and  cut  the  latter  out  with  scissors,  keeping  one-third  inch 
from  it  all  around.  The  bleeding  was  free,  but  the  vessels 
were  readily  secured.  The  sides  of  the  gap  were  drawn  to- 
gether in  the  form  of  -)-,  the  longitudinal  incision  closed 
with  sutures,  and  a  drainage  tube  placed  behind  the  bowel 
and  brought  out  at  the  posterior  angle  of  the  incision. 

B.  Resection  of  the  Rectum  from  below,  leaving  the 
Sphincter.  After  thoroughly  emptying  the  bowels  in  ad- 
vance the  patient  is  placed  in  the  lithotomy  position,  or  on 
the  side  with  the  hips  and  knees  flexed.  An  incision  is 
made  in  the  median  line  posteriorly  through  the  anus  and 
rectal  wall  below  the  disease,  and  carried  to  the  coccyx. 
With  a  sound  in  the  urethra  or  finger  in  the  vagina, 
another  incision  in  the  median  line  in  front  is  carried 
through  the  anus  and  lower  healthy  rectal  wall  into  the 
perineum.  The  buttocks  are  separated  and  the  lips  of 
these  incisions  drawn  apart  with  blunt  retractors. 

The  sound  rectum  is  then  divided  transversely  below  the 
disease  and  above  the  sphincter  by  lateral  incisions  joining 
the  upper  extremities  of  the  incisions  through  its  anterior 
and  posterior  walls.  By  working  with  the  fingers  and 
blunt-pointed  scissors  from  within  outward  through  the 
transverse  incisions  in  the  rectal  wall,  the  diseased  rectum 
above  is  separated  all  around  on  its  outer  surface  from  the 
surrounding  tissues  and  drawn  down.  The  vessels  are  tied 
as  they  are  cut,  but  if  the  dissection  is  made  mostly  by 
tearing  with  the  fingers  the  greater  part  of  the  hemorrhage 
can  be  arrested  by  pressure.  A  temporary  suture  with  the 
ends  left  long  is  then  passed  through  the  anterior  and 
posterior  walls  of  the  rectum  above  to  prevent  its  retraction, 
while  the  diseased  part  is  excised  by  a  transverse  division 


SPECIAL  OPERATIONS. 


457 


of  the  bowel   in  the  healthy  tissue  below  the  retention 
sutures. 

The  cut  euds  of  the  rectum  are  united  all  around  by  in- 
terrupted sutures  passed  with  a  sharply  curved  needle,  and 
then  the  incisions  in  its  anterior  and  posterior  walls.  A 
large  drainage  tube  surrouuded  by  light  packing  and  reach- 
ing above  the  point  of  division  is  placed  in  the  rectum, 
the  wounds  in  the  perineum  and  behind,  including  the 
sphincter,  are  closed  with  deep  sutures  and  a  drainage  tube 
placed  in  the  lower  angle  of  each. 

C.  ITueter's  Operation  by  a  Perineal  Flap.  (Fig.  237.) 
The  patient  occupies  the  lithotomy  position  and  a  sound  is 
introduced  into  the  urethra.  A  flap,  including  the  anus 
and  adjoining  part  of  the  perineum,  is  marked  out  of  an 
inverted  U-shape,  having  the  anus  a  little  in  front  of  the 
centre  of  the  base,  which  is  posterior.     To  form  this  an 


Fig.  237 


Resection  of  the  rectum,  showing  Hueter's  curved  incision.    The  straight 
incision  is  that  for  posterior  rectotomy. 

incision  is  made  through  the  skin  and  subcutaneous  tissue, 
starting  at  the  level  of  the  posterior  end  of  the  tuber 
ischii  outside  of  the  outer  border  of  the  sphincter  ani,  pass- 
ing forward  aud  crossing  the  perineum  close  to  the  poste- 
rior insertion  of  the  scrotum,  then  backward  to  terminate 
on  the  other  side  of  the  anus  outside  the  sphincter  opposite 
the  starting  point.    The  incision  is  deepened,  aud  anteriorly 


458  OPERATIVE  SURGERY. 

in  the  bend  of  the  U,  the  junction  of  the  accelerator  urinee 
with  the  compressor  urethra?  muscles  cut  through,  and  the 
flap  including  the  sphincter  ani  turned  down. 

Working  in  from  in  front  the  rectum  is  isolated  on  all 
sides  and  the  diseased  portion  excised  by  transverse  division 
of  the  bowel  through  healthy  tissue  above  and  below  the 
disease.  The  bleeding  in  this  large  wound  is  stopped  by 
ligation  or  pressure. 

The  cut  ends  of  the  rectum  are  brought  together  all 
around  with  sutures,  and  the  flap  replaced,  with  a  drain 
and  light  packing  in  each  lower  augle.  A  tube  and  pack- 
ing reaching  above  the  line  of  division  is  then  inserted 
through  the  anus.  The  mucous  membrane  might  first  be 
united  by  a  separate  row  of  sutures  not  entering  the  mus- 
cular coat,  which  is  afterward  brought  together  by  sutures 
of  catgut  penetrating  the  muscular  coat  alone,  so  as  to 
bring  the  suture  line  in  the  mucosa  below  that  in  the  mus- 
cularis  and  thus  make  communication  less  easy  for  the  feces 
from  the  interior  of  the  bowel  to  the  perirectal  tissue. 
Zuckerkandl's  method  for  reaching  the  seminal  vesicles 
(q.  v.)  is  very  similar  to  this  operation. 

D.  Resection  of  the  Rectum  from  behind  (Kraske's 
Operation)  with  Removal  of  the  Coccyx  and  part  of  the 
Sacrum.1  The  patient  is  placed  on  the  right  side  and  an 
incision  is  made  in  the  median  liue  from  the  middle  of  the 
sacrum  to  the  anus  and  carried  down  to  the  bone.  The 
fibres  of  the  gluteus  are  detached  from  the  lower  part  of 
the  left  half  of  the  sacrum  and  from  the  coccyx,  and  the 
latter  bone  removed.  The  left  side  of  the  incision  is  then 
drawn  forcibly  aside  and  the  greater  and  lesser  sacrosciatic 
ligaments  successively  divided  close  to  their  attachment  to 
the  sacrum.  This  gives  access  to  a  large  portion  of  the 
rectum,  but  if  more  room  is  desired  it  can  be  obtained  by 
chiselling  away  the  lower  left  part  of  the  sacrum  below  the 
third  sacral  foramen  and  including  the  fourth  without 
opening  the  sacral  canal.  The  anterior  branches  of  the 
fourth  and  fifth  sacral  nerves  are  necessarily  divided  in  this 
procedure. 

1  Arch.  f.  kiln.  Chlr.,  1886,  vol.  xxxiii.  p.  56G.    For  a  review  oi  this  operation 
and  its  modilications,  see  Frank  :  Wien.  klin.  Woch.,  1891,  vol.  iv.  p.  800. 


SPECIAL  OPERATIONS. 


459 


The  posterior  branches  and  the  fifth  nerve  are  of  no  im- 
portance, but  the  nerve-supply  of  the  levator  ani,  coccygeus, 
and  sphincter  ani  on  the  left  side  is  of  course  cut  off. 


Fig.  238. 


JDpper  half  of  fifth 

i-,     posterior  sacral  foramen. 


Resection  of  the  rectum  from  behind. 
A,  B.    Portion  of  the  sacrum  removed  in  Kraske's  operation. 
A,  C.    Hochenegg's  modification. 


Hochenegg's  modification  of  the  bone  removal  is  repre- 
sented in  Fig.  238. 

Bardenheuer  still  further  modified  it  by  the  removal  of 
all  the  sacrum  below  the  third  sacral  canal,  which  destroys 


460  OPERATIVE  SUEGEBY. 

the  possibility  of  subsequent  restoration  of  the  function  of 
the  sphincter. 

The  rectum  is  now  freed  by  division  of  the  connective 
tissue  binding  it  to  the  sacrum,  and  drawn  downward  so 
far  as  may  be  necessary  to  bring  the  subsequently  cut  ends 
of  the  gut  into  apposition  without  undue  tension  on  the 
sutures.  To  give  more  room  and  greater  protection  to  the 
important  male  organs  lying  close  in  front  of  the  rectum, 
the  sphincter  and  rectal  wall  from  the  anus  up  to  the  tumor 
can  be  cut  posteriorly  in  the  median  line;  but  it  is  not 
always  necessary. 

The  growth  is  then  freed  by  the  finger  and  blunt- pointed 
scissors  from  its  lateral  and  anterior  connections  and  ex- 
cised with  a  margin  of  healthy  tissue,  by  transverse  divi- 
sion of  the  rectum  above  and  below. 

If  the  relations  of  the  tumor  make  it  necessary,  the  peri- 
toneal cavity  must  be  opened  and  involved  portions  of  the 
peritoneum,  together  with  any  glands  which  can  be  felt, 
removed  with  the  tumor.  The  peritoneum  is  then  drawn 
together  with  fine  catgut  sutures  and  secured  against  infec- 
tion by  an  iodoform-gauze  packing.  The  anterior  half  of 
the  divided  bowel  is  united  by  silk  sutures  through  its 
mucous  and  muscular  coats,  while  the  posterior  half  is  left 
open  and,  if  possible,  sutured  to  the  skin  at  the  margins  of 
the  wound  ;  it  can  afterward  be  closed  by  a  secondary  oper- 
ation. 

If  the  anus  and  adjacent  rectal  wall  have  been  split  pos- 
teriorly, the  rectal  part  of  the  wound  is  closed  by  inter- 
rupted catgut  sutures  and  the  sphincter  drawn  together  by 
deep  silk  or  silver-wire  sutures  passed  in  the  manner 
described  for  restoring  a  completely  ruptured  perineum. 

The  overlying  parts  and  the  upper  and  lower  angles  of 
the  posterior  wound  are  drawn  together  with  silk  sutures, 
and  a  drainage-tube  and  packing  placed  in  each  angle. 
The  centre  of  the  wound,  with  the  open  half  of  the  rectum, 
is  packed  and  a  drainage  tube  passed  into  the  bowel  above. 
Afterward  the  patient  will  have  to  be  kept  on  a  water-bed. 

A  colotoray  performed  a  week  or  two  before  this  oper- 
ation is  of  great  assistance  in  keeping  the  wound  aseptic 
and  avoiding  the  very  frequent  and  early  dressings  other- 
wise necessary. 


SPECIAL  OPERATIONS.  461 

Heineke  recommends  an  L-shaped  incision  from  the  anus 
to  the  coccyx,  then  along  the  left  border  of  the  sacrum  up 
to  the  fourth  sacral  foramen,  and  then  transversely  to  the 
right  border  of  the  sacrum.  The  bone  is  chiselled  through 
in  this  line  aud  the  soft  part  of  the  flap  turned  down  and  to 
the  right.  Rydygier  dispenses  with  the  transverse  incision 
in  the  skin. 

Levy  divides  the  sacrum  transversely  a  finger's  breadth 
above  its  lower  extremity,  and  from  each  end  of  the  trans- 
verse incision  carries  one  downward  toward  the  ischial 
tuberosities,  the  soft  parts  attached  to  the  side  of  the  sacrum 
below  its  point  of  transverse  division  are  cut,  and  the  bone- 
and-skin  flap  turned  down. 

Hegar  employs  a  V-shaped  incision  starting  at  the  pos- 
terior inferior  spines  of  the  ilia  and  following  the  sides  of 
the  sacrum  to  the  tip  of  the  coccyx.  The  periosteum  is 
separated  from  the  anterior  surface  of  these  bones ;  the 
sacrum  sawed  transversely  and  turned  up. 

Almost  any  of  these  methods  of  operation  gives  access  to 
the  female  pelvic  organs. 


LIVER. 

Anatomy.  The  level  of  the  upper  surface  of  the  liver  is 
indicated  by  a  line  drawn  through  the  fifth  chondro  sternal 
articulation  on  the  right  side  and  through  the  sixth  on  the 
left.  It  is  uncovered  by  the  ribs  where  it  crosses  the  sub- 
costal angle,  from  the  ninth  right  to  the  eighth  left  costal 
cartilage.  The  left  lobe  extends  one  and  a  half  to  two 
inches  beyond  the  left  margin  of  the  sternum.  The  lung 
descends  over  the  upper  surface  of  the  diaphragm  and  liver 
on  the  right  side  to  the  lower  border  of  the  sixth  rib  in  the 
mammary  line,  in  the  mid-axillary  line  to  the  upper  border 
of  the  eighth  rib,  and  in  the  scapular  line  to  the  upper 
border  of  the  tenth  rib.  The  pleura  descends  about  half 
an  inch  lower,  following  the  costo-chondral  junction,  or  the 
bony  extremities  of  the  ribs,  aud  the  lower  border  of  the 
eleventh  rib.  As  the  twelfth  rib  is  sometimes  very  short, 
it  may  be  overlooked.  Therefore  the  ribs  should  be 
counted,  and  the  lower  edge  of  the  pleura  will  be  found 


462  OPERATIVE  SURGERY. 

passing  horizontally  from  the  lower  border  of  the  twelfth 
dorsal  vertebra  to  the  lower  border  of  the  eleventh  rib. 

The  gall-bladder  is  about  four  inches  long  and  an  inch 
wide,  and  normally  holds  about  au  ounce.  Its  fundus 
touches  the  abdominal  wall  immediately  below  the  ninth 
costal  cartilage  near  the  outer  border  of  the  right  rectus 
muscle.  The  cystic  duct  is  about  an  inch  long,  and  the 
common  duct  three  inches  long.  The  latter  descends  in 
the  right  border  of  the  lesser  omentum  behind  the  first 
portion  of  the  duodenum,  in  front  of  the  portal  vein  and  to 
the  right  of  the  hepatic  artery ;  it  then  passes  between  the 
pancreas  and  duodenum,  behind  the  pancreatico  duodenal  is 
artery,  to  empty  into  the  middle  of  the  inner  side  of  the 
second  portion  of  the  duodenum. 

Abscess  of  the  Liver.  An  incision,  preferably  longi- 
tudinal, three  or  four  inches  long  is  made  over  the  most 
prominent  part  of  the  tumor  below  the  ribs.  The  incision 
is  deepened  to  the  peritoneum,  and  if  the  liver  is  found 
adherent  beneath  this  incision  the  abscess  is  simply  in- 
cised for  about  an  inch  and  drained  with  a  large  tube,  and 
packing  if  necessary,  bearing  in  mind  the  very  friable 
character  of  the  abscess-walls.  If  the  liver  is  not  adherent 
where  the  abdomen  has  been  opened,  but  is  found  to  be  so 
at  some  other  spot  below  the  ribs,  another  incision  is 
made  through  the  parietes  over  this  spot,  and  the  abscess 
reached  through  the  safely  adherent  area.  The  first  in- 
cision, having  served  as  a  guide,  is  closed  in  the  usual  way 
and  well  protected  from  infection  before  the  abscess  is 
opened. 

If  the  abscess  must  be  opened  immediately,  and  there 
are  no  adhesions  to  the  parietal  peritoneum,  a  sponge  pack- 
ing is  inserted  to  protect  the  rest  of  the  abdominal  cavity, 
and  the  point  of  an  exploring-needle  buried  in  the  liver. 
The  piston  is  immediately  withdrawn  and  the  needle  slowly 
pushed  on  in  a  straight  line.  By  withdrawing  the  piston 
as  soon  as  possible  pus  will  flow  into  the  cylinder  when  it 
is  first  reached,  and  by  pushing  the  needle  always  in  a 
straight  line  unnecessary  and  easily-inflicted  damage  to  the 
gland  is  avoided.  If  the  first  exploration  fail,  the  needle 
must  be  taken  out  and  reinserted  in  different  straight  di- 
rections till  pus  is  found. 


SPECIAL  OPERATIONS.  463 

With  the  needle  as  a  guide,  a  knife  is  then  passed 
through  the  liver-substance  iuto  the  abscess-cavity,  while 
the  liver  is  kept  in  as  close  coutact  with  the  abdominal 
wall  as  possible,  rolliug  the  patient  on  oue  side  if  neces- 
sary. The  index-finger  is  quickly  passed  along  the  track 
of  the  knife  and  the  opening  enlarged  to  an  inch  or  more 
and  hooked  up  without  force  into  the  abdominal  wound. 
Hemorrhage  is  controlled  by  packing.  After  the  pus  has 
been  evacuated,  the  interior  of  the  abscess-cavity  is  irri- 
gated with  warm  boiled  water;  its  opening  is  then  plugged 
with  a  sponge,  and  the  parietal  peritoneum  and  the  skin 
around  the  margins  of  the  abdominal  wound  are  united  with 
catgut.  After  removal  of  the  protective  packing  from  the 
abdomen  the  liver  is  fastened  in  the  wound  by  interrupted 
catgut  or  fine  silk  sutures  passed  through  its  substance  at 
a  little  distance  outside  of  the  abscess-opening,  to  shut  off 
its  communication  with  the  general  peritoneum. 

If  the  stitches  show  a  tendency  to  tear  out,  sterilized 
gauze  must  be  packed  around  the  opening  in  the  liver  and 
the  ends  brought  out  of  the  abdominal  wound. 

The  sponge  plug  is  then  removed  and  a  large  drainage 
tube  inserted.  Immediately  before  incising  the  liver  an 
attempt  can  be  made  to  closely  unite  the  parietal  and  vis- 
ceral peritoneum  with  catgut  sutures  around  the  proposed 
area  of  the  incision.  But  the  stitches  may  tear  out  or 
puncture  and  cause  leakage  from  the  abscess  into  the  gen- 
eral peritoneal  cavity.  As  the  liver  ascends  and  descends 
with  respiration  it  cannot  be  fastened  to  the  abdominal 
wall  at  a  less  distance  than  half  an  inch  from  the  free 
border  of  the  ribs  and  costal  cartilages. 

Whenever  there  is  time  it  is  always  best  to  secure  firm 
adhesions  of  the  liver  to  the  parietes  in  the  selected  region 
before  evacuating  the  pus.  A  longitudinal  incision  two  or 
three  inches  long  is  carried  down  layer  by  layer  and  the 
peritoneum  opened  and  the  liver  exposed.  After  carefully 
protecting  the  surrounding  viscera  with  sponge,  the  pres- 
ence of  pus  is  verified  with  a  fine  aspirating  needle,  and 
the  point  of  puncture  is  then  covered  with  an  iodoform- 
gauze  packing  large  enough  to  hold  the  margins  of  the 
abdominal  wound  apart  and  in  contact  with  the  liver.  In 
addition,  the  parietal  peritoneum  and  skin  can  be  united 


464  OPERATIVE  SURGERY. 

with  catgut  around  the  margins  of  the  incision.  If  omen- 
tum should  happen  to  intervene  between  the  liver  and 
parietes  it  must  be  pushed  aside.  A  fairly  tight  antiseptic 
dressing  is  applied,  and  in  the  course  of  two  or  three  days 
adhesions  will  have  shut  off  the  abdominal  cavity  and  the 
abscess  can  be  safely  opened  without  an  anaesthetic. 

As  before  remarked,  some  surgeons  supplement  the  pack- 
ing placed  ou  the  exposed  surface  of  the  liver  to  cause  its 
adhesion  to  the  abdominal  wall  by  sutures  of  catgut  or  fine 
silk  passed  with  a  curved  needle  deeply  through  the  sub- 
stance of  the  liver  and  fastened  in  the  margins  of  the 
abdominal  incision.  But  they  are  unnecessary  and  dan- 
gerous from  possible  leakage  of  the  abscess  alongside  the 
sutures. 

It  is  generally  unwise  to  approach  an  abscess  of  the 
liver  through  the  thoracic  cavity  ;  but  if  unavoidable,  the 
selected  intercostal  space  should  be  enlarged  by  resection 
of  a  rib,  and  the  layers  of  the  parietal  and  diaphragmatic 
pleura  carefully  united  with  catgut  sutures  around  the  pro- 
posed line  of  drainage.  The  surface  of  the  liver  is  then 
exposed  by  an  incision  through  the  diaphragm  and  the 
future  drainage  track  packed  with  iodoform  gauze  till  ad- 
hesions have  formed. 

If  the  liver  and  diaphragm  are  already  adherent,  the 
abscess  can  be  opened  immediately,  provided  the  pleural 
cavity  is  secured  from  infection. 

It  is  unsafe  to  aspirate  a  possible  abscess  of  the  liver 
through  the  unopened  abdominal  or  thoracic  wall. 


HYDATID   CYST   OF   THE    LIVER. 

The  operative  treatment  of  hydatid  cyst  of  the  liver  is 
almost  identical  with  that  of  abscess.  After  partial  evacua- 
tion of  its  contents  by  a  trocar  and  canula  or  aspirating 
needle  the  cyst  wall  can  be  more  readily  drawn  into  the 
abdominal  wound  and  sutured  there,  and  thus  the  rest  of 
the  abdominal  cavity  is  more  effectually  protected  than  in 
the  case  of  an  abscess,  and  a  cyst  can  be  more  safely  opened 
immediately. 


SPECIAL  OPERATIONS. 


465 


Cholecystostomy.  (Fig.  239.)  An  incision  three  or  four 
inches  long  is  made  vertically  downward  from  the  lower 
border  of  the  liver  opposite  the  tip  of  the  cartilage  of  the 
tenth  rib  (Fig.  239),  and  deepened  layer  by  layer  and  the 
peritoneum  opened.  If  an  extensive  dissection  or  an  opera- 
tion on  the  cystic  or  common  duct  is  anticipated  more  room 
will  be  needed,  and  it  is  better  to  use  an  incision  about  four 
inches  long,  starting  from  the  median  line  an  inch  below 
the  ensiform  process,  extending  obliquely  downward  and 
outward,  and  terminating  horizontally  (Fig.  239).  If  the 
liver  is  enlarged  the  oblique  incision  should  follow  a  line 


-#^ 


Incisions  for  exposing'the  gall-bladder. 


parallel  to  and  just  above  its  free  border.  When  a  dis- 
tended gall-bladder  is  encountered  it  is  carefully  surrounded 
with  a  protective  sponge  packing  and  enough  fluid  drawn 
off  with  an  aspirator  to  allow  the  walls  thus  relaxed  to  be 
pinched  up  on  each  side  of  the  needle  by  the  fingers  or 
padded  forceps  and  drawn  into  the  abdominal  wound. 
Sponges  are  wedged  arouud  it  to  prevent  leakage  into  the 
peritoneum,  and  the  fluid  is  evacuated  by  a  trocar  and 
canula,  or  a  knife  plunged  into  the  bladder  wall  at  the 
point  of  puncture  made  by  the  needle.  In  selecting  this 
point  of  puncture  allowance  must  be  made  for  retraction  of 
a  distended  bladder.    If  the  bladder  is  not  distended  irnme- 


466  OPERATIVE  SURGERY. 

diately  after  opening  the  abdomen  a  finger  is  passed  along 
its  inner  surface  following  the  cystic  and  common  duct,  to 
explore  for  the  trouble  as  far  as  the  intestine.  A  careful 
dissection  with  the  finger  nail  and  blunt-pointed  scissors 
may  be  necessary  to  separate  adhesions  to  surroundiug 
viscera  and  even  to  find  the  gall-bladder. 

After  protecting  the  rest  of  the  abdominal  cavity  with  a 
sponge  packing  the  fundus  of  the  bladder  is  drawn  as  far 
as  possible  into  the  abdominal  wound  and  opened  enough  to 
admit  one  finger.  All  stones  are  then  gently  scooped  or 
irrigated  out,  the  abdominal  wound  partially  closed  in  the 
usual  way,  and  the  protective  sponges  removed.  The  gall- 
bladder is  fastened  in  the  opened  part  of  the  wound  by  a 
continuous  silk  suture  passed  through  the  skin,  peritoneum, 
and  the  whole  thickness  of  the  bladder  wall  around  the 
margin  of  the  opening  iu  it.  The  suture  line  must  be  far 
enough  away  from  the  free  border  of  the  ribs  to  allow  for 
the  respiratory  movements  of  the  liver.  Some  operators 
precede  the  continuous  suture  through  all  coats  of  the 
bladder  with  interrupted  sutures  uniting  its  serous  coat  to 
the  parietal  peritoneum  ;  but  this  is  unnecessary. 

A  large  rubber  drainage  tube  is  passed  into  the  fistulous 
opening  and  an  abundant  absorbent  dressing  applied  which 
will  need  frequent  renewal.  It  is  not  advisable  to  close  a 
wound  of  the  gall  bladder  by  the  Czerny-Lembert  method 
of  suture  and  leave  no  communication  with  the  abdominal 
incision. 

Operations  Involving  the  Cydie  or  Common  Bile  Duct. 
(Fig.  229.)  The  oblique  incision  is  used,  or  the  vertical 
changed  later  if  necessary  into  a  crucial  or  J -shaped  in- 
cision. After  locating  the  stone  by  the  exploring  finger 
and  protecting  the  rest  of  the  abdomen  by  a  sponge  pack- 
ing, an  attempt  is  made  to  manipulate  the  calculus  back 
into  the  bladder  or  forward  into  the  intestine,  but  with  the 
recollection  that  the  ducts  are  easily  lacerated  and  very 
slightly  distensible. 

If  it  seem  feasible  to  reach  the  stone  from  the  interior  of 
the  gall-bladder,  this  viscus  is  opened  in  the  manner  already 
described,  and  one  of  the  specially  devised  cholelithotomy 
forceps  used  to  clip  or  nibble  the  stone  into  fragments, 


SPECIAL  OPERATIONS.  467 

guided  by  the  other  hand  in  the  abdomen.  The  operation 
is  completed  as  described  for  cholecystostomy.  On  the 
same  principle  an  impacted  calculus  has  been  crushed  by 
padded  forceps  applied  to  the  exterior  of  the  duct,  and  has 
been  broken  by  the  point  of  an  aspirating  needle  punc- 
turing the  duct.  Dr.  McBurney  extracted  one  after  split- 
ting the  distal  portion  of  the  duct  through  an  opening  made 
in  the  duodenum  for  the  purpose.  For  a  stone  otherwise 
irremovable  from  the  cystic  duct  cholecystectomy  is  pre- 
ferable to  needling  or  crushing  externally  with  padded  for- 
ceps. But  there  must  be  no  doubt  about  the  patency  of  the 
common  duct. 

For  a  calculus  impacted  below  the  cystic  duct,  the  ob- 
lique abdominal  incision  is  used  and  the  surrounding  viscera 
are  well  protected  and  retracted  by  a  sponge  packing.  The 
duct  is  opened  in  its  long  axis  over  the  stone  sufficiently  to 
extract  the  latter,  and  the  opening  then  closed  by  inter- 
rupted Czerny-Lembert  sutures,  which  is  more  possible  than 
it  sounds,  owing  to  the  generally  increased  thickness  of  the 
duct  wall  from  the  irritation  caused  by  the  presence  of  the 
calculus.  A  drainage  tube  and  iodoform  gauze  packing  is 
carried  from  the  abdominal  wound  down  to  the  neighbor- 
hood of  the  suture  line  and  the  abdominal  wound  partially 
closed  in  the  usual  way. 

If  an  opened  gall  bladder  must  be  sutured  in  the  abdomi- 
nal wound  at  the  same  time,  its  opening  must  be  separated 
as  far  as  possible  from  the  drainage  tube  by  intermediate 
suturing. 

CHOLECYSTENTEROSTOMY. 

This  term  is  used  to  designate  the  establishment  of  a 
permanent  fistulous  communication  between  the  gall  blad- 
der and  the  intestine.  The  operation  is  designed  to  create 
a  route  by  which  the  bile  can  pass  into  the  intestine  when  the 
common  duct  is  permanently  obstructed,  and  when  both 
the  cystic  and  hepatic  ducts  are  patent  and  communicate, 
and  for  some  cases  of  persistent  biliary  fistula.  The  abdo- 
men is  opened,  preferably  by  the  vertical  incision,  and  a 
convenient  loop  of  intestine  as  near  the  duodenum  as  pos- 
sible is  isolated  by  iodoform-gauze  bands  tied  around  the 


468  OPERATIVE  SURGERY. 

gut  above  and  below,  and  to  this  isolated  loop  the  gall- 
bladder is  sutured  and  the  communication  established  in 
the  same  manner  as  described  for  intestinal  anastomosis. 

The  bladder  is  first  emptied  by  an  aspirating  needle 
entered  as  near  as  possible  to  the  site  of  the  future  fistula. 
A  continuous  fine  silk  suture  is  passed  uniting  the  serous 
coats  of  the  bladder  and  the  intestine  at  the  convex  free 
border  of  the  latter  for  a  distance  of  about  an  inch  and  a 
half,  and  in  front  of  this,  as  the  parts  lie  exposed,  a  row 
of  Lembert  sutures  is  inserted.  After  carefully  protecting 
the  surrounding  parts  by  a  fresh  sponge  packing,  the  op- 
posing surfaces  of  the  gall-bladder  and  intestine  are  opened 
longitudinally  for  about  an  inch  close  in  front  of  the  Lem- 
bert sutures,  and  the  interior  of  each  irrigated  clean.  The 
mucous  membranes  are  united  by  a  continuous  fine  silk  or 
catgut  suture,  and  a  row  of  Lembert  sutures  continuous 
with  those  already  in  place  completes  the  serous  apposition 
all  around.  The  gauze,  constricting  bauds,  and  sponges  are 
removed  and  an  iodoform-gauze  packing  placed  around  the 
suture  line  and  the  ends  brought  out  of  the  abdominal 
wound,  which  is  partially  closed  in  the  usual  way. 

Murphy,  of  Chicago,1  has  invented  a  mechanical  con- 
trivance called  an  "anastomosis  button"  for  establishing  a 
fistula  between  any  of  the  hollow  viscera  without  the  em- 
ployment of  sutures.  It  consists  of  two  buttons  which 
slide  on  a  hollow  cylinder,  so  arranged  with  a  spring  that 
the  opposed  margins  of  their  concave  surfaces  are  kept  in 
contact  and  cause  a  pressure-necrosis  of  the  visceral  walls 
in  their  grasp,  thus  making  a  hole  in  the  diameter  of  the 
button,  which  is  later  passed  in  the  feces. 

However  it  may  be  criticised  for  other  purposes,  it  seems 
a  peculiarly  valuable  contrivance  for  performing  cholecyst- 
enterostomy.  The  button  can  be  made  small  enough  to 
be  easily  passed  off  by  the  intestine,  and  at  the  same  time 
leave  a  communication  with  the  gall-bladder  large  enough 
to  be  useful  in  spite  of  any  probable  subsequent  cicatricial 
contraction. 

The  abdomen  is  opened  by  the  vertical  incision,  the  blad- 
der is  aspirated,  and  a  selected  loop  of  intestine  isolated  as 

1  New  York  Med.  Rec,  Dec.  10, 1892. 


SPECIAL  OPERATIONS.  469 

usual,  and  a  protective  sponge  packing  placed  in  the  abdo- 
men. A  "purse-string"  suture  of  fine  silk  is  passed 
through  the  serous  coat  of  the  bladder  and  intestine  en- 
closing an  area  on  each  large  enough  to  contain  a  slit  the 
length  of  the  diameter  of  the  buttons.  The  buttons  are 
inserted  in  the  longitudinal  slits  then  made  in  the  bladder 
and  gut,  and  the  wounds  are  drawn  tight  around  the  central 
cylinder  by  tying  the  sutures.  The  buttons  are  simply 
pressed  together,  and  the  wounds,  with  the  suture  in  each, 
are  shut  within  the  concavity  bounded  by  the  margins  of 
the  buttons  holding  the  serous  surfaces  in  apposition. 

The  calculi  are  not  disturbed,  but  left  to  be  defecated 
with  the  button,  and  the  abdominal  wound  is  closed  with- 
out drainage  after  removing  the  sponges. 


CHOLECYSTECTOMY. 

The  abdomen  is  opened  by  the  oblique  incision  and  the 
gall-bladder  surrounded  with  sponges.  Starting  at  the 
fundus,  an  incision  is  made  on  each  side  of  the  bladder 
through  the  peritoneum  at  a  little  distance  from  the  liver, 
and  the  bladder  dissected  out  with  blunt-pointed  scissors 
as  far  as  the  cystic  duct.  The  latter  is  divided  between  a 
double  ligature  of  silk  and  the  peritoneal  flaps  closed  over 
the  liver  by  a  continuous  catgut  suture.  The  abdominal 
wound  is  partially  closed  around  a  tube,  and  light  iodoform- 
gauze  packing  carried  down  to  the  former  site  of  the  gall- 
bladder. 

SPLEEN. 

Anatomy.  The  pedicle  of  the  spleen  will  be  formed  by 
the  gastro-splenic  omentum  passing  from  the  hilum  to  the 
stomach  and,  continuous  with  this  above,  the  suspensory 
ligament  passing  to  the  diaphragm.  The  splenic  artery 
lies  above  the  vein  behind  the  upper  border  of  the  pan- 
creas. The  gastro-splenic  omentum  contains  its  terminal 
five  or  six  branches  which  arise  at  a  variable  distance  from 
the  spleen  and  may  enter  its  hilum  over  a  considerable 
area.     Most  of  the  vasa  brevia  arise  from  these  and  turn 

21 


470  OPERATIVE  SURGERY. 

backward  to  the  stomach,  and  near  the  termination  of  the 
main  splenic  artery  the  gastro-epiploica  sinistra  is  given  off. 
The  venous  branches  correspond  to  the  arterial. 


SPLENECTOMY. 

A  vertical  incision  three  or  four  inches  long  is  made 
along  the  outer  border  of  the  left  rectus  muscle  above  the 
umbilicus,  and  the  peritoneum  opened.  If  the  spleen  has 
prolapsed  into  an  already  existing  wound,  the  latter  is 
simply  enlarged  as  much  as  necessary.  Adhesions  are 
separated  or  divided  between  double  catgut  ligatures,  and 
the  tumor,  which  must  be  very  gently  handled,  is  fully  ex- 
posed. After  surrounding  it  with  a  sponge  packing  it  is 
turned  out  of  the  abdominal  wound,  generally  the  lower 
end  first.  The  abdominal  opening  should  be  made  large 
enough  to  allow  the  tumor  to  pass  without  force,  and  the 
margins  of  the  wound  should  be  held  back  to  avoid  all 
traction  on  the  pedicle.  Startiug  at  its  lower  edge,  suc- 
cessive pairs  of  artery  clamps  are  applied  to  the  pedicle 
in  advance  of  the  line  of  division  which  is  then  made  be- 
tween them. 

The  spleen  is  then  removed  and  the  vessels  in  the  grasp 
of  each  clamp  are  ligated  separately  with  silk.  As  each 
clamp  is  removed  bleeding  points  are  sought  for  and  secured ; 
after  this  Greig  Smith  advises  that  the  whole  pedicle  be  sur- 
rounded by  a  ligature  drawn  moderately  tight  to  lessen  the 
arterial  pressure  distal  to  it  on  the  ligatures  of  each  vessel. 
The  abdominal  wound  is  then  closed  tight  in  the  usual  way. 


KIDNEY. 

Anatomy.  The  kidney  lies  imbedded  in  fatty  tissue 
which  is  more  abundant  behind  than  in  front,  and  from 
which  it  can  be  easily  enucleated.  Posteriorly  the  upper 
half  rests  against  the  diaphragm  and  the  lower  half  upon 
the  transversalis  aponeurosis,  and  is  crossed  posteriorly  by 
the  last  dorsal,  the  ilio-hypogastric,  and  ilio-inguinal  nerves. 
In  front,  from  above  downward,  the  liver,  duodenum,  and 


SPECIAL  OPERATIONS.  471 

hepatic  flexure  of  the  colon  are  in  contact  with  the  right 
kidney ;  the  stomach  with  the  spleen  externally,  the  pan- 
creas, and  descending  colon  are  in  relation  with  the  anterior 
surface  of  the  left  kidney. 

Thus  the  colon  generally  lies  vertically  in  front  of  a 
renal  growth  on  the  right  side,  and  ou  the  left  side  crosses 
it  obliquely  from  above  downward  and  outward.  The 
peritoneum  over  such  a  tumor  can  be  divided  on  the  outer 
side  of  the  colon,  but  not  on  the  inner,  without  interfering 
with  the  blood-supply  of  the  bowel. 

The  renal  artery,  which  may  divide  into  one  or  more 
branches  before  entering  the  hilum,  subdivides  into  ter- 
minal branches,  which  are  said  commonly  to  lie  in  front 
of  the  veins.  The  renal  vein  subdivides  earlier  than  the 
artery,  and  the  left  vein  receives  the  left  spermatic  and  left 
inferior  phrenic  veins  which  are  within  reach  of  injury 
during  treatment  of  the  renal  pedicle.  The  vessels  lie  in 
front  of  the  ureter,  which  terminates  near  the  lower  border 
of  the  kidney  in  its  pelvis.  The  latter  subdivides  in  the 
hilum  into  two  or  three  short  trunks  (infundibula), 
which  in  turn  subdivide  into  the  calices  opening  over 
the  papillae ;  so  that  a  finger  cannot  pass  from  the  pelvis 
into  the  first  subdivision  and  much  less  into  the  second  or 
calices. 

As  the  twelfth  rib  may  be  rudimentary  or  absent  the 
ribs  should  always  be  counted  before  a  lumbar  operation, 
in  order  to  avoid  the  pleura,  which  is  generally  found  to 
pass  horizontally  from  the  lower  border  of  the  twelfth 
dorsal  vertebra  to  the  lower  border  of  the  eleventh  rib. 


EXPOSURE   OF   THE  KIDNEY. 

Lumbar  Methods.  The  patient  lies  upon  the  sound  side 
with  a  sand-bag  under  the  loin  to  widen  the  opposite  ex- 
posed costo-iliac  space. 

A.  The  longitudinal  incision  is  made  along  the  outer 
border  of  the  muscular  mass  formed  by  the  erector  spina? 
and  sacro-lumbalis,  which  is  about  two  and  a  half  to  three 
inches  from  the  vertebral  spines,  and  it  should  extend 
through  the  skin  from  the  eleventh  rib  to  the  iliac  crest. 


472  OPERATIVE  SURGERY. 

(Fig.  240.)  It  is  deepened  through  the  middle  layer  of  the 
lumbar  fascia  or  the  aponeurosis  of  the  trausversalis,  and 
the  posterior  surface  of  the  quadratus  lumborum  is  exposed. 
The  outer  border  of  the  muscle  is  cleared  and  drawn  toward 
the  spine,  and  after  retraction  of  the  sides  of  the  wound, 
the  peri-renal  fat  can  usually  be  seen  through  the  thin  ante- 
rior layer  of  the  lumbar  fascia,  moving  synchronously  with 
respiration.  Space  can  be  advantageously  gained  by  divid- 
ing the  outer  portion  of  the  quadratus  close  to  its  attach- 
ment to  the  ilium. 

Fig.  240. 


Incisions  for  exposing  the  kidney.    L.  Longitudinal  or  vertical  incision. 
T.  Transverse  incision.    K.  Konig's  incision. 


On  division  of  the  thin  intervening  fascia  the  fatty  cap- 
sule of  the  kidney  is  reached,  and  by  tearing  through  it 
and  stripping  it  toward  the  sides  the  posterior  surface  of 
the  middle  and  lower  portions  of  the  kidney  and  its  pelvis 
are  exposed  to  sight  and  touch.  At  the  outer  border  of  the 
quadratus  muscle  the  last  dorsal,  the  ilio-hypogastric,  and 
ilio-inguinal  nerves  will  be  encountered,  and  one  or  all  may 
be  divided  if  they  cannot  be  sufficiently  retracted. 

Some  additional  space  can  be  gained  by  drawing  the  last 
rib  forcibly  upward  with  a  blunt  hook,  which  is  safer  than 


SPECIAL  OPERATIONS.  473 

resection  of  a  portion  of  the  twelfth  and  even  the  eleventh 
rib,  as  has  been  done  in  a  few  cases.  If  the  pleural  or 
peritoneal  cavity  is  accidentally  opened,  the  rent  should  be 
immediately  closed  with  fine  catgut  sutures  and  protected 
by  an  iodoform-gauze  packing. 

Except  in  persons  who  are  very  fat,  this  incision  gives 
ample  room  for  exploration,  nephropexy,  nephrotomy,  and 
even  for  nephrectomy  when  the  kidney  is  not  very  much 
enlarged. 

B.  The  transverse  incision  (Fig.  240,  T)  is  begun  just 
within  the  outer  margin  of  the  sacro-lumbalis,  a  little 
below  the  twelfth  rib,  and  carried  outward  parallel  to  the 
rib  for  about  four  inches.  The  muscular  and  aponeurotic 
layers  are  successively  divided  after  recognition,  until  the 
retro-peritoneal  layer  is  reached,  and  the  kidney  exposed 
by  division  of  its  fatty  capsule,  as  in  the  preceding  descrip- 
tion. Additional  space  can  be  gained  by  a  short  longi- 
tudinal cut  at  the  inner  (vertebral)  end  of  the  main 
incision. 

This  incision  is  advantageous  in  nephrectomy  when  the 
kidney  is  much  enlarged,  and  whenever  it  may  be  necessary 
to  insert  a  hand  into  the  peritoneal  cavity. 

C.  The  combined  longitudinal  and  transverse  incision 
consists  of  the  longitudinal  incision  joined  at  any  part  by 
the  transverse. 

D.  Konig's  incision1  (Fig.  240,  K).  Starting  from  the 
last  rib,  the  incision  passes  vertically  downward  along  the 
outer  border  of  the  sacro-lumbalis  and  erector  spinas,  curves 
forward  just  above  the  highest  part  of  the  iliac  crest,  and 
passes  horizontally  toward  the  umbilicus  to  end  at  the  outer 
border  of  the  right  rectus.  The  vertical  part  of  the  incision 
is  deepened  first  and  carried  down  layer  by  layer  until  the 
peritoneum  is  reached  in  front  of  the  anterior  layer  of  the 
lumbar  fascia.  After  the  fingers  are  placed  in  the  lower 
angle  of  this  wound  to  protect  the  peritoneum  beneath  the 
horizontal  part,  the  latter  is  deepened  through  the  succes- 
sive muscular  layers  until  the  peritoneum  is  exposed.     It 

1  Oeutralbl.  f.  Chir.,  18S6,  No.  35,  p.  593. 


474  OPERATIVE  SURGERY. 

may  often  be  advisable  to  make  the  vertical  part  of  the 
incision  run  obliquely  iuto  the  horizontal  in  the  form  of  a 
flattened  curve.  This  incision  affords  very  free  access  to 
the  kidney  and  a  good  part  of  the  ureter,  and  the  size  of 
the  wound  does  not  materially  add  to  the  risks,  but  rather 
lessens  them  by  the  increased  facility  afforded  for  dealing 
with  the  pedicle  or  any  complications. 

At  the  close  of  the  operation  the  divided  muscles  in  the 
horizontal  and  curved  parts  of  the  incision  are  united  by 
deep  sutures  and  heal  readily,  while  the  vertical  part  can 
be  packed  and  drained  if  necessary.  In  any  ordinary  case 
the  horizontal  part  of  this  incision  need  not  be  extended 
beyond  the  vertical  prolongation  of  the  anterior  axillary 
line. 

Nephrotomy.  The  kidney  is  exposed  by  the  lougitudiual 
lumbar  incision,  and  if  the  abscess  or  cyst  which  has  made 
the  operation  necessary  is  perfectly  apparent  it  only  remains 
to  cut  into  the  most  prominent  part  of  the  diseased  tissue 
with  the  knife  or  thermo-cautery.  But  if  there  is  any 
doubt  about  the  presence  or  location  of  the  disease  it  must 
be  sought  by  an  aspirating  needle  passed  through  the 
convex  border  of  the  kidney  and  its  track  followed  by  a 
knife.  A  finger  then  plugs  and  enlarges  this  incision  while, 
if  necessary,  an  assistant  makes  counter-pressure  through 
the  anterior  abdominal  wall  to  lift  the  kidney  into  the  in- 
cision ;  then  if  the  cavity  is  very  irregular,  or  if  there  are 
separate  pouches,  the  septa  should  be  freely  broken  down 
to  secure  efficient  drainage,  and  the  interior  of  the  cavity 
thoroughly  scraped  with  a  sharp  spoon  if  its  condition  re- 
quires it. 

Occasionally  it  will  be  possible  and  desirable  to  draw  the 
edges  of  the  sac  iuto  the  parietal  wound  and  stitch  them  to 
the  skin  or  deeper  tissues.  Rubber  tubes  packed  around 
with  iodoform  gauze  are  passed  into  all  parts  of  the  abscess 
cavity  for  drainage,  and  into  any  spaces  in  the  cellular 
tissue  about  the  kidney  which  may  have  been  opened  up 
and  infected. 

The  extremities  of  the  external  wound  are  drawn  to- 
gether with  silk,  and  a  large  absorbent  dressing  applied. 


SPECIAL  OPERATIONS.  475 

Nephrolithotomy.  After  the  kidney  has  been  exposed, 
preferably  by  Konig's  incision,  which  also  gives  access  to 
the  upper  part  of  the  ureter,  the  surgeon  proceeds  to  seek 
for  signs  of  the  presence  and  location  of  a  calculus ;  the 
horizontal  part  of  this  incision  should  not  be  made  at  first 
of  the  full  length,  but  later  it  is  prolonged  if  found  neces- 
sary. 

The  posterior  surface  of  the  gland  is  freed  and  the  kid- 
ney palpated  between  the  thumb  and  finger  and  any  click 
or  spot  of  especial  density  noted. 

A  fine  needle  is  then  passed  systematically  through  the 
cortex  or  wall  of  the  pelvis  at  intervals  of  half  an  inch, 
and  not  deeper  than  two  and  a  half  inches  in  a  normal 
adult  kidney,  in  order  to  avoid  possible  injury  to  the  main 
vessels.  Should  this  fail  to  detect  the  stone,  some  authors 
recommend  that  the  finger  should  be  introduced  through 
an  incision  in  the  cortex  and  thus  a  thorough  digital 
examination  be  made  of  the  interior  of  the  pelvis  and 
calices.  , 

If  no  stone  is  found  the  wound  is  closed  with  catgut 
sutures  passed  through  the  substance  of  the  kidney,  and 
the  external  wound  is  brought  together  around  a  drainage 
tube  placed  in  contact  with  the  renal  wound.  But  unless 
the  operator  feels  very  sure  of  his  diagnosis  this  method 
of  exploration  should  not  be  carried  out. 

When  a  stone  is  felt  by  the  needle,  an  incision  is  made 
with  the  knife  or  thermo-cautery  through  the  cortex  longi- 
tudinally or  in  a  liue  radiating  from  the  pelvis  to  the  con- 
vex border.  Unless  it  is  very  manifestly  better  to  open 
the  pelvis  directly,  an  incision  through  the  cortex  is 
preferable  to  one  through  the  walls  of  the  pelvis  on  account 
of  the  less  danger  of  a  urinary  fistula  and  troublesome 
hemorrhage.  The  latter  can  be  readily  checked  by  the 
pressure  of  the  finger  or  by  a  catgut  suture  passed  deeply 
through  the  renal  substance. 

Through  the  opening  thus  made  the  stone  is  picked  or 
scooped  out.  If  it  is  large  or  branched  it  may  have  to  be 
crushed  witli  a  lithotrite  or  strong  sequestrum  forceps ; 
septa  should  be  divided  with  blunt-pointed  scissors ; 
occasionally  stones  have  been  encountered  so  large,  or  so 
numerous  and  difficult  of  removal,  that  nephrectomy  has 


476  OPERATIVE  SURGERY. 

been  considered  wiser  than  nephrolithotomy.  After  re- 
moval of  the  stone  the  orifice  of  the  ureter  is  sought  and 
that  canal  explored  to  determine  whether  it  is  free  or  whether 
plugged  by  a  stone  or  mass  of  fibrin.  If  such  an  obstruction 
is  fouud  it  may  be  pushed  back  iuto  the  kidney,  or  washed 
out  by  a  stream  of  water  directed  into  the  distended  ureter 
through  the  renal  wound,  or  perhaps  pushed  downward 
into  the  bladder. 

The  stone  or  stones  having  been  extracted  from  the  kid- 
ney, the  wound  in  its  substance  or  in  the  pelvic  wall  is 
closed  with  catgut  sutures  unless  there  is  so  much  sup- 
puration present  that  every  facility  must  be  given  for  the 
escape  of  pus.  Sometimes  the  gland  will  have  become  a 
mere  abscess  cavity  containing  the  stone.  Rubber  tubes 
and  iodoform-gauze  packing  are  placed  in  contact  with  the 
kidney  wound  or  in  its  interior,  as  its  condition  may  re- 
quire, and  in  the  space  possibly  opened  up  behind  it.  A 
strip  of  gauze  is  carried  down  to  the  peritoneum  beneath 
the  curved  part  of  the  external  wound,  if  Konig's  incision 
has  been  used,  and  the  wound  closed  with  silk  sutures  up 
to  the  space  where  the  drainage  emerges. 

Lumbar  Nephrectomy.  The  kidney  is  exposed  by 
Konig's  incision,  but,  if  there  is  any  doubt  about  its  re- 
moval, it  should  first  be  explored  by  the  longitudinal 
incision,  and  afterward  a  transverse  incision  of  the  neces- 
sary length  can  be  added  at  any  convenient  part  of  the 
longitudinal.  The  length  of  the  transverse  or  horizontal 
part  of  Konig's  incision  is  regulated  by  the  size  of  the 
tumor.  If  inflammation  has  not  materially  changed  the 
tissues  immediately  surrounding  the  kidney,  it  is  compara- 
tively easy,  after  reaching  its  posterior  surface  and  tearing 
through  the  perirenal  fat,  to  work  the  fingers  in  close  con- 
tact with  the  capsule  around  the  convex  border  and  the 
two  extremities  and  enucleate  the  kidney  from  its  bed  by 
separating  all  the  attachments  except  the  pedicle  constituted 
by  the  renal  vessels  and  the  ureter. 

In  cases  of  long-continued  suppuration  where  every- 
thing has  become  matted  together,  as,  for  instance,  after 
nephrotomy  for  abscess,  it  may  be  easier  to  open  the  capsule 
and  separate  the  kidney  from  its  interior.     The  manipula- 


SPECIAL  OPERATIONS.  477 

tions  must  be  gentle  and  without  undue  traction  on  the 
pedicle,  and  if  abnormal  vessels  are  encountered  at  the 
extremities  of  the  gland  they  should  be  divided  between 
double  catgut  ligatures.  After  isolation  of  the  pedicle  it 
may  be  tied  off  in  sections  by  silk  ligatures  passed  on  a 
large  full  curved  aneurism  pedicle  needle  ;  occasionally  the 
main  artery  can  be  recognized  by  sight  or  touch,  and  it  is 
desirable  that  it,  as  well  as  the  ureter,  should  receive  a 
separate  ligature  whenever  possible.  If  the  pedicle  cannot 
be  isolated  and  brought  into  view  or  reached  on  account  of 
the  condition  or  situation  of  the  adhesions,  the  entire 
pedicle  can  be  tied  en  masse,  preferably  by  the  elastic  liga- 
ture, which  is  drawn  tight  by  the  fingers  in  the  depths  of 
the  wound  and  retained  by  a  knot  or  stout  clamp. 

The  part  of  the  kidney  substance  distal  to  the  ligature  is 
then  cut  away,  leaving  enough  margin  to  prevent  slipping 
of  the  ligature,  and  the  large  stump  which  sometimes  re- 
mains when  the  adhesions  to  the  anterior  surface  have  been 
very  extensive  is  scraped  as  much  as  is  safe  and  the  elastic 
ligature  is  left  to  slough  out.  Occasionally  the  pedicle  may 
be  secured  by  a  long,  strong  clamp  till  the  kidney  is  excised 
and  then  the  pedicle  is  tied  by  one  or  more  ligatures  on  the 
proximal  side  of  the  clamp.  If  the  ureter  has  been 
separately  divided  it  is  well  to  close  it  with  a  ligature,  and 
if  necessary  to  disinfect  the  stump  or  fix  it  in  the  external 
wound.  The  pedicle  is  finally  again  inspected  to  avoid  any 
chance  of  hemorrhage,  and  then  after  the  insertion  of 
rubber  drainage  tubes  and  iodoform-gauze  packing  the 
external  wound  is  partially  closed. 

During  the  course  of  a  nephrectomy  it  may  be  necessary 
to  enter  the  abdominal  cavity ;  this  can  be  done  through 
the  anterior  extremity  of  Konig's  or  of  the  trausverse  in- 
cision ;  the  surrounding  peritoneal  cavity  is  protected  by  the 
usual  sponge  packing,  and  after  removal  of  the  latter  at  the 
close  of  the  operation  an  iodoform-gauze  packing  is  inserted 
unless  there  is  a  certainty  of  asepsis,  in  which  case  the 
peritoneum  can  be  again  closed  tight. 

Abdominal  Nephrectomy.  The  place  of  selection  for  the 
parietal  incision  is  at  the  outer  border  of  the  rectus  muscle, 
where    it  is  sometimes  called  Langenbuch's  incision.     It 

21* 


478  OPERATIVE  SURGERY. 

should  not  be  less  than  four  inches  long,  and  should  have 
its  centre  as  nearly  as  possible  opposite  the  centre  of  the 
tumor.  The  incision  is  sometimes  made  parallel  to  this,  but 
further  outward  with  the  idea  of  making  the  operation  wholly 
extra-peritoneal,  and  then  it  is  only  a  modification  of  lumbar 
nephrectomy  by  the  longitudinal  incision.  Sometimes  the 
abdomen  is  opened  in  the  median  line.  After  division  of 
the  tissues  in  successive  layers,  including  the  peritoneum, 
the  viscera  are  pushed  aside  and  protected  by  flat  spouges 
or  brought  out  of  the  abdomen  and  wrapped  in  warm 
cloths. 

The  peritoneum  over  nearly  the  whole  length  of  the  en- 
larged kidney  is  then  incised  longitudinally  on  the  outer 
side  of  the  colon  in  order  not  to  interfere  with  the  blood- 
supply  of  the  latter.  This  must  always  be  done  in  this  way 
unless  the  size  of  the  tumor  and  the  position  of  the  colon 
make  it  impracticable.  Occasionally  it  is  possible,  as 
shown  by  Halsted,  to  attach  the  edges  of  the  divided  peri- 
toneum covering  the  kidney  to  those  of  the  divided  anterior 
parietal  peritoneum,  and  thus  entirely  to  shut  off  the  gen- 
eral peritoneal  cavity  from  the  field  of  operation.  By  work- 
ing with  the  fingers  or  blunt-pointed  scissors  the  peritoneum 
is  stripped  from  the  anterior  surface  of  the  gland  and  the 
structures  at  the  hilum  exposed.  All  vessels,  as  they  are 
encountered,  are  secured  in  advance  whenever  possible  and 
divided  between  double  ligatures.  It  may  even  be  advan- 
tageous to  go  directly  to  the  artery  through  a  special  inci- 
sion in  the  peritoneum  aud  tie  it  as  the  first  step  in  the 
operation.  The  ureter  is  then  isolated  between  two  liga- 
tures, and  if  extensively  diseased  it  is  brought  out  of  the 
abdomen  behind  and  fastened  to  the  skin  through  the  wound 
made  in  the  loin  for  drainage;  or  if  healthy  the  stump  is 
simply  disinfected  and  left. 

During  the  removal  of  the  kidney  every  effort  must  be 
made  to  avoid  infection  of  the  peritoneal  cavity  by  its  con- 
tents or  those  of  the  ureter.  After  this  the  gap  in  the  pos- 
terior parietal  peritoneum  may  be  rapidly  closed  with  a 
continuous  catgut  suture,  and  lumbar  drainage  provided 
for  the  space  formerly  occupied  by  the  kidney  by  the  inser- 
tion of  a  rubber  tube  and  gauze,  if  necessary,  through  a 
small  incision  made  in  the  loin.     The  abdominal  wound  is 


SPECIAL  OPERATIONS.  479 

closed  in  the  usual  way,  with  or  without  drainage,  accord- 
ing to  the  necessities  of  the  case. 

The  presence  and  condition  of  the  other  presumably 
sound  kidney  should  always  be  ascertained  as  soon  as  the 
peritoneal  cavity  is  opened  iu  abdominal  nephrectomy. 

In  cases  of  floating  kidney  in  which  the  gland  is  fully 
pedunculated  and  invested  by  peritoneum,  its  removal  will 
be  conducted  as  in  the  case  of  auy  other  pedunculated  ab- 
dominal tumor,  without  stripping  off  the  peritoneum. 

Neurorrhaphy  or  Nephropexy.  This  is  the  operation  by 
which  an  abnormally  movable  kidney  is  permanently  fixed 
in  its  proper  position  by  suturing  it  to  the  abdominal  wall. 

The  kidney  is  exposed  by  the  longitudinal  lumbar  in- 
cision at  the  outer  border  of  the  sacro-lumbalis,  and  the 
fatty  capsule  divided  longitudinally  and  stripped  back 
from  the  surface  of  the  kidney.  Three  or  four  stout  catgut 
or  silkworm-gut  sutures  are  then  passed  with  a  curved 
needle  from  the  anterior  to  the  posterior  surface,  well 
within  the  convex  border,  at  intervals  of  about  half  an 
inch,  and  then  through  the  cut  edge  of  the  lumbar  fascia  in 
the  inner  lip  of  the  wound,  so  that  when  tied  they  hold  the 
kidney  snugly  up  against  the  abdominal  wall.  The  wound 
may  then  be  closed  for  primary  union,  or  packed  with 
iodoform  gauze  to  heal  by  granulation.  Guyon  sought  to 
strengthen  the  cicatricial  connection  by  removing  a  lung 
strip  of  the  fibrous  capsule ;  and  Sulzer1  recommends  that 
the  capsule  be  split  and  reflected  so  as  to  form  a  flap  which 
can  be  stitched  in  the  parietal  wound. 


UEETEE. 

Anatomy.2,  The  ureter  lies  behind  the  peritoneum  on  the 
psoas  muscle  and  genito-crural  nerve  in  the  upper  part  of 
its  course,  and  is  crossed  from  within  outward  by  the  sper- 
matic or  ovarian  vessels.  As  the  ureters  approach  the  pelvis 
they  lie  close  to  the  spine  between  the  psoas  and  the  body 
of  the  vertebra,  the  right  ureter  being  a  little  further  out- 

1  Deut.  Zeit.  f.  Chir.,  vol.  xxxi. 

2  Cabot :  American  Journal  of  the  Medical  Sciences,  1892,  vol.  ciii.  p.  43. 


480  OPERATIVE  SURGERY. 

ward  than  the  left,  owing  to  the  interposition  of  the  in- 
ferior vena  cava,  with  which  it  is  in  close  relationship. 

When  the  peritoneum  in  this  region  is  stripped  up  from 
the  parts  beneath  the  ureter  will  always  be  found  adhering 
to  its  under  surface  and  on  the  left  side,  about  half  an  inch 
to  an  inch  outside  of  the  point  where  the  peritoneum  be- 
comes attached  to  the  spine ;  on  the  right  side  the  distance 
is  slightly  greater.  The  ureters  cross  the  common  or  ex- 
ternal iliac  vessels  to  enter  the  pelvis,  where  they  lie  pretty 
closely  over  the  lateral  edges  of  the  sacrum.  They  then 
run  in  the  recto- vesical  fold  of  peritoneum  to  enter  the  base 
of  the  bladder  at  a  distance  of  two  inches  from  each  other 
and  pass  for  a  half  to  three-quarters  of  an  inch  between 
the  mucous  and  muscular  coats  of  the  viscus  before  termi- 
nating. The  vas  deferens  is  between  the  ureter  and  the 
bladder.  The  narrowest  part  of  the  canal  is  close  to  the 
bladder,  and  this  region,  which  is  the  most  difficult  of  access, 
is  also  the  one  where  a  calculus  is  most  likely  to  lodge.  In 
the  female  the  ureter  for  the  last  two,  and  in  some  cases 
three,  inches  of  its  course,  lies  in  the  broad  ligament  in 
close  relationship  with  the  cervix  and  vault  of  the  vagina, 
and  it  can  be  reached  by  an  incision  in  the  vault  extending 
outward  and  backward  within  the  layers  of  the  broad  liga- 
ment. 

Operations  on  the  Ureter}  Almost  the  only  indications 
for  operations  upon  the  ureter  are  found  in  wounds  of  it 
or  in  the  necessity  for  the  removal  of  an  impacted  calculus. 
The  ureter  should  always  be  opened  extra-peritoneally  for 
the  removal  of  a  stone,  inasmuch  as  the  wound  cannot  be 
satisfactorily  closed  with  sutures,  and  it  has  been  proven 
that  at  least  a  longitudinal  wound  will  in  time,  if  there  is 
proper  drainage,  spontaneously  close  and  allow  the  urine  to 
pass  in  its  natural  channel. 

The  ureter  should  generally  first  be  explored  through  a 
median  abdominal  opening  made  below  the  umbilicus,  and 
always  thus  explored  if  there  is  doubt  about  the  location  of 
the  stone.  In  some  instances  it  has  thus  been  possible  to 
manipulate  the  calculus  up  into  the  pelvis  of  the  kidney  or 

1  A  Bummary  of  this  subject  with  the  bibliography  will  he  round  In  the  Annals 
of  Surgery,  1894,  p.  267. 


SPECIAL  OPERATIONS.  481 

down  into  the  bladder,  and  even  when  it  was  soft  to  break 
the  stone  into  fragments  with  the  fingers  and  then  get  them 
into  the  bladder. 

If  the  ureter  must  be  opened,  an  incision  is  made  three 
or  four  inches  long  wherever  necessary  in  a  line  drawn 
from  a  point  on  the  anterior  edge  of  the  sacro-lumbalis  a 
finger's  breadth  below  the  twelfth  rib,  parallel  to  the  rib  as 
far  as  its  tip,  thence  downward  toward  the  middle  of  Pou- 
part's  ligament  till  about  opposite  the  anterior  superior 
spine  of  the  ilium.  From  this  point  the  line  again  turns 
inward  to  end  at  the  outer  border  of  the  rectus  muscle. 

The  tissues  are  divided  layer  by  layer  till  the  peritoneum 
is  reached,  and  then  the  latter  membrane  is  gently  raised 
by  the  fingers  from  the  parts  beneath  till  the  ureter  is  ex- 
posed adhering  to  its  under  surface.  In  the  middle  third 
of  the  course  of  the  ureter  it  will  be  found  about  half  an 
inch  to  an  inch  from  the  spinal  attachment  of  the  peri- 
toneum. The  ureter  is  incised  longitudiually  over  the  stone 
sufficiently  to  extract  the  latter.  In  several  instances  this 
wound  has  then  been  closed  by  a  continuous  suture  of  fine 
silk  through  the  outer  wall  of  the  ureter,  but  not  penetrat- 
ing its  lumen,  and  with  one  end  of  the  suture  left  within 
reach  from  the  parietal  opening  to  remove  it  in  case  of  sup- 
puration. This  may  at  any  rate  narrow  the  opening  and 
so  hasten  its  repair,  though  Cabot1  considers  suturing  a 
wound  of  the  ureter  unnecessary. 

A  rubber  tube  aud  iodoform-gauze  packing  is  placed  in 
contact  with  the  ureteral  wound  for  drainage  of  escaping 
urine,  and  the  ends  brought  out  of  the  exterual  incision 
which  is  partially  closed  around  them. 

In  some  cases  where  the  stone  can  be  felt  through  the 
vault  of  the  vagina,  and  it  is  between  the  layers  of  the 
broad  ligament  not  more  than  an  inch  or  an  inch  and  a 
half  from  the  bladder,  an  incision  can  be  made  in  the 
vault  outward  and  backward  and  the  finger  pushed  up 
separating  the  intervening  tissues  in  the  broad  ligament  till 
the  stone  is  reached.  The  ureter  is  then  opened  longitudi- 
nally on  its  under  side  and  the  stone  picked  out.  This 
wound  has  been    successfully  closed  with  sutures,  but  it 

1  Loc.  cit. 


482  OPERATIVE  SUBGEBY. 

will  generally  be  found  sufficient  to  place  a  drainage  tube 
and  packing  in  contact  with  it  and  bring  the  ends  out 
through  the  vagina.1 

In  other  cases  if  the  stone  has  reached  the  bladder  cavity 
and  lies  between  the  mucous  and  muscular  coats,  it  should 
be  attacked  through  the  interior  of  the  bladder,  probably 
by  a  suprapubic  cystotomy ;  but,  if  it  is  further  off  and 
the  bladder  wall  must  be  opened  to  expose  the  stone,  there  is 
great  danger  of  urinary  infiltration  in  the  surrounding 
parts,  and  Cabot's  method,  described  below,  should  be  used. 

With  these  exceptions  the  lower  third  of  the  ureter  must 
generally  be  approached  from  behind.  An  incision  is  made 
three  or  four  inches  long,  starting  just  below  the  tip  of  the 
coccyx  and  following  the  lateral  border  of  that  bone  and 
the  sacrum  on  the  side  of  the  affected  ureter.  The  sacro- 
sciatic  ligaments  are  divided  close  to  the  sacrum  and  the 
coccyx  excised,  and  if  necessary  the  lower  lateral  border  of 
the  sacrum  also,  as  in  Kraske's  operation. 

With  a  large  sound  in  the  rectum  to  map  it  out  and  push 
it  aside,  the  ureter  is  sought  for  close  to  the  edge  of  the 
sacrum  and  opened  longitudinally  on  its  under  side  opposite 
the  calculus  sufficiently  to  extract  the  latter.  The  resulting 
wound  is  simply  packed  and  drained. 

Wounds  of  the  Ureter.  Extraperitoneal  wounds  of  the 
ureter  involving  a  part  of  its  circumference  should  be 
treated  as  already  described,  i.  e.y  by  a  counter-opening  and 
drainage  through  the  abdominal  wall  in  a  direction  as 
nearly  as  possible  directly  backward.  When  the  wound 
has  been  intraperitoneal  or  has  involved  the  entire  circum- 
ference of  the  ureter,  the  divided  ends  have  been  ligated 
with  catgut  and  the  stumps  disinfected  and  covered  with 
an  iodoform-gauze  packing,  which  was  brought  out  of  the 
abdomen,  and  the  corresponding  kidney  has  then  been 
extirpated. 

Or,  after  ligating  and  disinfecting  the  divided  lower 
end  of  the  ureter,  the  upper  end  has  been  brought  out  in 
the  loin  through  a  counter-opening  made  above  the  crest 
of  the  ilium  behind,  and  a  urinary  fistula  established,  for 
the  cure  of  which  nephrectomy  has  been  subsequently  per- 
formed. 

1  Cabot :  Loc.  cit. 


SPECIAL  OPERATIONS.  483 

Some  recent  experiments  on  dogs1  seem  to  prove  that 
one  ueter  can  be  implanted  in  the  rectum,  or  colon,  with- 
out especial  danger  or  subsequent  inconvenience,  and  this 
fact  might  be  of  great  service  in  case  of  an  accidental  divi- 
sion of  one  ureter  during  a  pelvic  operation. 

There  is  also  reason  to  believe  that  it  may  be  possible  to 
obtain  reunion  of  the  divided  ureter  and  re-establishment 
of  the  flow  of  urine  to  the  bladder  by  partial  suturing  of 
the  divided  ends  after  trimming  them  obliquely  or  into  cor- 
responding salient  and  re-entrant  Vs.  If  union  can  be 
thus  obtained  over  a  part  of  the  wall,  the  remaining  fistula 
may  heal  as  after  longitudinal  or  oblique  wounds. 

In  several  reported  instances,  when  it  has  been  divided 
near  its  lower  end,  the  ureter  has  been  implanted  in  the 
bladder  above  the  point  where  it  normally  enters  this  viscus. 
The  cut  end  of  the  ureter  is  slit  up  longitudinally  for  half 
an  inch  and  its  margins  sutured  with  catgut  to  the  edges  of 
an  opening  iu  the  bladder.    Drainage  must  be  provided  for. 

Kelly2  has  successfully  employed  on  the  human  subject  a 
method  used  by  Van  Hook  in  experiments  on  dogs,  and  has 
called  the  operation  uretero-ureterostomy.  Other  similar 
cases  are  being  reported.  The  divided  extremity  of  the  distal 
segment  is  tied  off  by  a  ligature  and  just  below  the  latter  the 
lumen  of  the  distal  segment  is  opened  longitudinally  suffi- 
ciently to  permit  the  upper  segment  to  be  inserted  into  the 
lower.  A  couple  of  sutures  in  the  cut  edge  of  the  proxi- 
mal stump  are  threaded  on  needles  and  passed  through  the 
slit  into  the  lumen  of  the  lower  stump  and  out  through 
its  walls  just  below  the  longitudinal  opening  and  used  to 
draw  the  upper  into  the  lower  portion  of  the  tube.  The 
ends  of  these  sutures  are  tied,  and  one  or  two  others 
inserted  at  the  point  where  the  stumps  are  in  contact. 
Gauze  is  then  packed  around  the  suture  line  and  brought 
out  of  the  abdominal  wound  for  drainage. 

CASTRATION. 

The  usual  preparations  for  an  antiseptic  operation  are 
made,  and  a  sterilized  towel  wet  in  a  1:1000  solution  of 

1  Annals  Surgery,  1892,  vol.  xvi.  p.  193.  2  Annals  Surgery,  1894,  p.  70. 


484  OPERATIVE  SURGERY. 

bichloride  of  mercury  is  wrapped  around  the  penis  and 
pinned  to  the  loose  skin  at  its  root.  The  scrotum  on  the 
affected  side  is  grasped  by  the  thumb  aud  fingers  of  the 
left  hand  and  drawn  tight  in  such  a  way  as  to  make  the 
diseased  testis  and  its  cord  prominent  and  tense.  An  in- 
cision is  then  made  from  the  external  abdominal  ring  along 
the  entire  length  of  the  anterior  portion  of  the  scrotum ; 
but  if  the  skin  is  involved  this  incision  should  be  made 
elliptical  in  the  direction  required  to  include  the  diseased 
area. 

After  division  of  the  skin  and  dartos  the  testicle  is 
slipped  out  of  the  wound,  and  the  remainder  of  the  dis- 
section and  isolation  of  the  gland  and  cord  is  completed 
more  by  tearing  with  the  fingers  and  blunt-pointed  scissors 
than  with  the  knife.  The  tunica  vaginalis  may  be  opened 
or  not,  and  is  removed  with  the  testicle. 

A  part  of  the  cord  is  selected  well  above  the  disease, 
and,  if  necessary,  the  inguinal  canal  is  opened  by  division 
of  the  tissues  over  it  in  successive  layers.  A  silk  thread  is 
passed  through  the  cord  to  insure  control  of  it,  and  then 
the  latter  is  divided  through  the  sound  portion  by  repeated 
cuts  of  the  knife  and  the  vessels  are  caught  and  tied  with 
catgut  as  they  bleed.  Hemorrhage  from  the  scrotal  wound 
must  be  completely  checked  by  ligation  or  by  torsion  and 
pressure. 

There  should  be  three  arteries  in  the  stump,  the  sper- 
matic, the  artery  of  the  vas,  and  the  cremasteric.  The 
ligatures  are  all  cut  short  and  the  internal  incision  is  closed 
by  interrupted  sutures  of  fine  silk,  taking  care  not  to  in- 
vert the  edges  of  the  scrotal  portion.  Drainage  is  unnec- 
essary unless  the  wound  has  been  exposed  to  infection,  in 
which  case  a  small  rubber  tube  with  lateral  perforations  is 
placed  in  its  depths  and  brought  out  at  the  most  dependent 
angle,  while  the  surface  is  partially  drawn  together  around 
an  iodoform-gauze  packing.  Sometimes  a  healthy  part  of 
the  cord  cannot  be  reached  and  it  must  be  tied  through 
diseased  tissue.  It  is  then  especially  necessary  to  ligate 
each  vessel  separately,  and  an  iodoform-gauze  packing  is 
placed  in  contact  with  the  stump. 

A  dry  dressing  is  applied  with  a  hernia  bandage,  over 
which  is  placed  a  sheet  of  rubber  tissue,  perforated  for  the 


SPECIAL  OPERATIONS.  485 

penis,  to  prevent  soiling  by  urine,  and  the  whole  retained 
by  a  flannel  spica  bandage. 


HYDROCELE. 

The  operations  for  the  relief  of  hydrocele  are  palliative 
or  radical.  The  object  of  the  former  is  simply  to  remove 
the  liquid  from  the  sac ;  that  of  the  latter  to  prevent  its 
reaccumulation  by  excising  the  sac,  or  by  obliterating  its 
cavity  by  exciting  adhesive  inflammation  of  its  walls. 
Injection  of  the  tincture  of  iodine  is  the  means  most  com- 
monly employed  for  the  latter  purpose.  The  position  of 
the  testicle  within  the  sac  should  always  be  ascertained,  in 
order  that  it  may  not  be  injured  by  the  trocar.  This  is 
best  accomplished  in  most  cases  by  examining  the  sac  by 
transmitted  light,  the  testicle  appearing  as  an  opaque  spot 
in  the  general  translucency ;  its  usual  position  is  at  the 
lower  posterior  portion  of  the  sac. 

Puncture  of  the  Sac.  After  the  adoption  of  every  anti- 
septic precaution  the  tumor  is  grasped  at  its  upper  portion 
in  such  a  manner  as  thoroughly  to  stretch  the  skin  covering 
it,  and  a  sterilized  trocar  is  plunged  into  the  centre  of  its 
anterior  surface,  supposing  the  testicle  to  occupy  its  usual 
position  below  and  behind.  The  depth  to  which  the  trocar 
enters  is  regulated  by  the  finger  placed  along  its  side,  and 
the  surgeon  satisfies  himself  that  the  point  is  well  within 
the  sac  by  moving  it  freely  in  all  directions.  The  canula 
should  fit  the  trocar  snugly  in  order  that  its  anterior  end 
may  not  push  the  tissues  before  it  instead  of  penetrating 
them.  If  the  intention  is  only  to  remove  the  liquid,  the 
canula  is  withdrawn  as  soon  as  the  flow  has  ceased,  and  the 
puucture  closed  with  adhesive  plaster  or  collodion  ;  but  if  a 
radical  cure  is  to  be  attempted,  the  tincture  of  iodine  must 
first  be  thrown  in.  The  French  surgeons  use  the  tincture 
diluted  with  two  or  three  parts  of  water,  and  prevent 
precipitation  by  adding  iodide  of  potassium  to  the  mixture. 
They  throw  a  considerable  quantity  into  the  sac,  retain  it 
there  for  three,  four,  or  five  minutes,  and  then  withdraw  it. 


486  OPERA  TIVE  S  UR  GER  Y. 

Van  Buren  and  Keyes1  recommend  the  "  pure  tincture 
thrown  iu  gradually,  retained  several  minutes,  and  worked 
around  in  such  a  way  that  every  portion  of  the  inner  wall 
of  the  sac  may  come  into  contact  with  it ; "  the  quantity  of 
the  tincture  used  should  be  equal  to  half  the  amount  of 
liquid  drawn  off.  Large  hydroceles  must  first  be  reduced 
in  size  by  one  or  two  tappings.  The  injection  of  fifteen  to 
thirty  minims  of  95  per  cent,  carbolic  acid  has  given  good 
results. 

Care  must  be  taken  that  the  injection  is  not  thrown  into 
the  subcutaneous  connective  tissue,  an  accident  that  is  very 
likely  to  be  followed  by  sloughing  of  the  scrotum  ;  the  surest 
way  of  avoiding  this  accident  is  to  throw  in  the  injection 
before  the  liquid  has  entirely  ceased  to  flow  out.  If  the 
accident  does  occur,  free  incisions  must  be  made  at  once 
into  the  scrotum  at  the  seat  of  the  infiltration. 

Radical  Cure  by  Excision  (Volkmanu).  With  every 
antiseptic  precaution  the  sac  is  freely  laid  open  by  a  longi- 
tudinal anterior  incision  and  the  cut  edges  of  the  skin  and 
tunica  vaginalis  stitched  together  all  around.  The  cavity 
is  then  lightly  packed  and  allowed  to  heal  by  granulation,  a 
process  which  requires  a  couple  of  weeks.  If  the  surgeon 
is  sure  of  the  asepsis  the  packing  may  be  withdrawn  at  the 
end  of  three  days,  aud  then,  by  applying  firm  pressure,  the 
wound  can  be  caused  to  heal  much  sooner. 


VARICOCELE. 

The  treatment  of  varicocele  may  be  palliative  or  radical. 
By  the  former,  support  is  given  to  the  testicle  and  the  over- 
distended  veins ;  by  the  latter,  it  is  sought  to  obliterate  the 
lumen  of  the  veins  at  one  or  more  poiuts.  There  are  several 
risks  involved  in  the  radical  treatment,  which,  when  taken 
in  connection  with  the  usual  harmlessuess  of  the  affection 
and  the  efficacy  of  palliative  measures,  should  make  the 
surgeon  slow  to  employ  it.  The  risks  are  :  Possible  phle- 
bitis, which  may  lead  to  pyaemia  ;  possible  atrophy  of  the 
testicle,  in  consequence  of  the  obliteration  of  all  the  veins 

1  Genlto-Urinary  Discuses  with  Syphilis,  New  York,  1874,  i>.  104. 


SPECIAL  OPERATIONS.  487 

or  the  inclusion  of  the  artery  in  the  ligature ;  and,  finally, 
the  likelihood  of  a  return  of  the  affection  if  all  the  veins 
are  not  obliterated.  The  palliative  treatment  consists  in 
wearing  a  suspensory  bandage,  or  in  excising  a  large  portion 
of  the  scrotum,  with  the  expectation  that  what  is  left  will 
act  as  a  natural  suspensory. 

Excision  of  the  Scrotum.  A  long  clamp  is  required, 
between  the  blades  of  which  a  large  fold  of  the  scrotum  is 
pinched  up  parallel  to  and  including  the  raphe.  This  fold 
is  then  cut  off  about  one-eighth  of  an  inch  from  the  outer 
side  of  the  blades,  and  numerous  interrupted  sutures  applied 
before  the  clamp  is  removed.  If  bleeding  is  feared,  these 
sutures  should  be  cut  about  a  foot  long,  and  not  tied  until 
after  the  clamp  has  been  taken  off  and  all  bleeding  points 
secured. 

The  radical  treatment  consists  in  obliterating  the  lumen 
of  the  veins  by  dividing  them  with  the  knife  or  the  cautery, 
excising  a  portion  of  their  length,  compressing  and  strangu- 
lating them  by  means  of  ligatures  or  clamps,  or  simply 
exposing  them  to  the  air.  Of  these  excision  is  the  only 
method  to  be  commended. 

Subcutaneous  Ligature.  A  needle  carrying  a  catgut  or 
antiseptic  silk  ligature  is  passed  through  between  the  veins 
and  the  cord,  reentered  at  the  point  of  emergence,  passed 
around  the  other  side  of  the  veins  close  under  the  skin  and 
brought  out  and  tightly  tied  at  the  first  point  of  entry.  If 
this  is  very  exactly  done,  so  as  not  to  include  the  deeper 
part  of  the  skin  at  either  puncture  in  the  loop,  and  is  treated 
antiseptically,  it  will  usually  heal  without  suppuration. 
Its  execution  is  facilitated  by  making  the  punctures  with  a 
knife. 

Open  Method  of  Ligation.  A  fold  of  the  scrotum  over 
the  enlarged  veins  above  the  globus  major  is  pinched  up 
and  divided  with  scissors,  making  a  longitudinal  incision 
about  an  inch  loug.  The  thumb  and  forefinger  of  the  left 
hand  grasp  the  vas  deferens,  pushing  it  backward,  while 
the  veins  at  the  same  time  are  forced  forward  into  the 
cutaneous  wound.      The  veins  are  isolated    by  a   slight 


488  OPERATIVE  SURGERY. 

dissection  with  the  knife  or  blunt-pointed  scissors  and  a 
ligature  of  catgut  or  fine  silk  is  passed  under  them  by  an 
aneurism  needle.  After  another  inspection  to  make  certain 
the  vas  is  not  included,  the  ligature  is  tied  tightly  and  the 
ends  cut  short.  The  small  incision  is  then  closed  without 
Irainage  and  closed  antiseptically. 

Some  surgeons  pass  the  ligature  double,  tying  off  a 
knuckle  of  vein,  which  is  then  excised  and  the  divided 
ends  brought  into  apposition  by  the  long  ends  of  the  lig- 
ature, which  are  then  cut  short. 


AMPUTATION    OF   THE    PENIS. 

Partial.  The  root  of  the  penis  is  constricted  by  a  piece 
of  rubber  tubing  and  the  skin  is  slightly  drawn  back 
toward  the  pubes  and  divided  by  a  circular  sweep  of  the 
knife.  With  a  sound  in  the  urethra  the  corpora  cavernosa 
are  cut  transversely  at  the  level  of  the  retracted  skin  down 
to  the  corpus  spongiosum,  which  is  then  dissected  out  by  a 
few  strokes  of  the  knife,  and,  after  withdrawal  of  the 
sound,  is  cut  transversely,  including  the  urethra,  about 
half  an  in  inch  louger  than  the  corpora  cavernosa  to  allow 
for  retraction  of  the  urethra.  The  cut  ends  of  the  vessels 
in  sight,  including  the  two  dorsal  arteries  and  the  arteries 
of  the  corpora  cavernosa,  which  lie  in  the  centre  of  these 
bodies,  are  tied  with  fine  catgut,  the  tourniquet  removed, 
and,  after  checking  the  hemorrhage  by  ligation  or  torsion, 
the  cut  edges  of  the  urethra  and  skin  are  united  with  fine 
silk. 

To  prevent  cicatricial  contraction  of  the  mouth  of  the 
urethra,  the  latter  should  be  split  longitudinally  for  about 
half  an  inch  on  its  under  surface  before  stitching  it  to  the 
skin. 

Complete.  The  patient  is  placed  in  the  lithotomy  posi- 
tion, a  sound  introduced  into  the  bladder,  and  the  scrotum 
is  split  from  before  backward  along  its  raphe.  The  corpus 
spongiosum  is  dissected  out  as  far  as  the  triangular  liga- 
ment, and  divided  about  an  inch  in  front  of  the  latter  after 
withdrawal  of  the  sound. 

A  circular   incision    continuous   with   the   anterior   ex- 


SPECIAL  OPERATIONS.  489 

tremity  of  the  scrotal  incision  is  next  made  through  the 
skin  around  the  root  of  the  penis  ;  the  suspensory  ligament 
is  divided,  and  by  dragging  on  the  penis  and  retracting  the 
sides  of  the  scrotal  wound,  the  corpora  cavernosa  and  their 
posterior  prolongations,  the  crura,  are  removed  from  the 
rami  of  the  pubes  and  ischium  by  the  knife  or  periosteal 
elevator.  All  the  attachments  of  the  penis  having  thus 
been  severed  and  the  bleeding  points  tied,  as  they  are  en- 
countered, with  fine  catgut,  the  urethra  is  split  for  half  an 
inch  on  its  floor  and  sutured  to  the  edges  of  the  wound 
well  forward  in  the  perineum,  and  the  remainder  of  the 
wound  is  united  between  the  testicles  so  as  to  form  a  sepa- 
rate scrotum  for  each  of  them. 

When  this  extensive  operation  is  undertaken  for  cancer 
of  the  penis  the  inguinal  glands  on  both  sides  should  be 
removed  at  the  same  time,  whether  perceptibly  enlarged  or 
not. 

OPERATIONS   FOR   PHIMOSIS. 

Dorsal  Incision.  A  director  is  passed  through  the  pre- 
putial orifice  along  the  dorsum  of  the  glans  to  the  corona, 
a  curved,  sharp-pointed  bistoury  guided  along  it,  the  skin 
transfixed  at  the  point  of  the  director  and  divided  straight 
down  to  the  preputial  orifice.  Nothing  more  is  absolutely 
required,  for  the  wound  left  to  itself  will  heal  promptly ; 
but  it  is  well  to  round  off  the  corners  and  to  unite  the  edges 
of  the  mucous  membrane  and  skin  by  fine  sutures.  This  is 
a  very  satisfactory  operation  when  the  prepuce  is  not  redund- 
ant, but  if  there  is  much  excess  of  tissue  the  foreskin  will 
present  an  awkward,  lop-eared  appearance  for  many  years, 
and  in  such  cases,  therefore,  circumcision  is  to  be  preferred. 

This  operation  is  often  required  in  cases  of  sub-preputial 
chancroid,  and  then  it  becomes  a  matter  of  considerable 
importance  to  prevent  inoculation  of  the  wound  by  the 
chancroidal  virus.  A  method  introduced  by  Dr.  J.  H. 
Lowman  into  the  venereal  wards  of  Charity  Hospital,  New 
York,  has  proved  very  efficient  in  this  respect.  A  solution 
of  nitrate  of  silver,  forty  grains  to  the  ounce,  is  injected 
under  the  prepuce,  and  followed  by  the  injection  of  a  satu- 
rated solution  of  common  salt,  to  remove  the  excess  of  the 
caustic.     The  sore  having  been  thus  rendered  temporarily 


490  OPERATIVE  SURGERY. 

innocuous  by  the  coagulation  of  its  secretions,  the  incision 
is  made  and  the  sore  cauterized  with  nitric  acid. 

Circumcision.  A  number  of  instruments  have  been  in- 
vented and  a  great  variety  of  methods  proposed,  which  do 
not  need  to  be  repeated  here,  for  the  object  they  had  in 
view,  that  of  insuring  division  of  the  skin  and  mucous  mem- 
braue  of  the  prepuce  at  the  same  level,  is  not  a  matter  of 
much  importance,  since  any  excess  of  the  latter  can  be 
readily  removed  afterward.  There  is,  however,  one  modi- 
fication iutroduced  by  Dr.  Keyes1  which  is  of  great  im- 
portance, for  it  insures  the  removal  of  the  coustriction  and 
protects  the  wound  from  beiug  harmed  by  erections  while 
healing.  This  modification  consists  in  an  additional  longi- 
tudinal division  of  the  skin  for  about  half  an  inch  along  the 
dorsum  of  the  penis,  and  sometimes,  also,  on  the  opposite 
side  along  the  course  of  the  urethra,  after  the  end  of  the 
prepuce  has  been  cut  off  (Fig.  242,  AC).  The  corners 
left  by  these  incisions  are  rounded  oif,  and  the  effect  is  to 
increase  the  circumference  by  twice  the  length  of  the  inci- 
sion. As  the  stricture  is  sometimes  due  to  insufficient 
breadth  of  the  skin  covering  the  glans,  the  value  of  this 
simple  modification  is  evident. 

Operation.  A  probe  is  first  introduced  and  swept  over 
the  surface  of  the  glans  to  break  up  any  adhesions  that 
may  exist,  and  the  edge  of  the  preputial  orifice  is  then 
caught  at  opposite  points  with  the  thumb  and  forefinger  of 
each  hand  and  drawn  forward,  care  being  taken  to  make 
the  tension  upon  the  less  elastic  mucous  membrane,  and  not 
only  upon  the  skin.  While  the  prepuce  is  thus  drawn  for- 
ward, an  assistant  clasps  a  pair  of  long  narrow-bladed 
forceps  vertically  upon  it  just  in  front  of  the  apex  of  the 
glans,  directing  the  blades  forward  as  well  as  downward 
(the  penis  being  horizontal)  parallel  to  the  general  direc- 
tion of  the  corona,  and  the  glans  should  then  be  moved 
freely  behind  them  to  make  sure  that  it  is  not  caught  be- 
tween the  blades.  The  portion  of  prepuce  in  front  of  the 
forceps  is  then  cut  away  with  scissors  or  a  knife  (Fig.  241) 
and  the  forceps  taken  off. 

1  Van  Jiuren  mid  Keyes :  Genito-Urinary  Diseases,  with  Syphilis,  New  York, 
1874,  p.  11, 


SPECIAL  OPERATIONS. 

Fig.  241. 


491 


Fig.  242. 


Circumcision.    First  incision. 

It  will  then  be  seen  that  the  glans  is  still  covered  by  a 
more  or  less  tightly  fitting  sheath  of  raucous  membrane, 
while  the  looser   and  more  elastic  skin 
retracts  to  or  beyond  the  corona,  leaving 
a  belt  of  raw  surface  below  (Fig.  242). 

The  mucous  membrane  is  next  divided 
with  scissors  along  the  dorsum  back  to 
the  corona  (Fig.  242,  BU),  and  the  skin 
divided  in  the  same  direction  along  the 
dorsum  for  a  distance  of  half  an  inch  from 
its  cut  edge  (Fig.  242,  AC),  and  also  on 
the  under  side  along  the  urethra,  if  con- 
sidered necessary.  The  corners  of  these 
incisions  are  rounded  off,  and  the  edges 
of  the  mucous  membrane  and  skin  fasten- 
ed together  with  numerous  fine  sutures, 
the  first  being  placed  exactly  in  the  me- 
dian line  in  front,  the  second  at  the 
frsenum.  If  fine  silk  is  used,  and  the 
sutures  placed  close  to  the  edge,  they  may  be  left  to  cut 
their  way  out  and  come  away  in  the  dressings. 


circumcision .  Raw 
surface  left  by  retrac- 
tion after  first  inci- 
sion. 


492 


OPERATIVE  SURGERY. 


It  is  always  difficult  to  get  accurate  adjustment  of  the 
edges  at  the  ends  of  the  longitudinal  incisious  on  the  dor- 
sum, and  usually  a  small  triangular  gap  is  left  to  fill  by 
granulation.  Dr.  D.  B.  Delavau1  proposes  to  meet  this 
objection  by  leaving  a  triangular  piece  projecting  in  the 
centre  of  the  dorsal  portion  of  the  cutaneous  incision.  Fig. 
243  shows  the  line  of  incision,  Fig.  244  the  resulting  tri- 
angles of  skin  and  mucous  membrane ;  the  apex  of  the  latter, 
H,  which  at  first  is  drawn  upward  by  its  close  connection 


Fig.  243. 


Fig.  244. 


Circumcision.    Delavan.    First  incision. 


Circumcision.    Delavan.    Fitting  in 
the  triangle. 


with  the  apex  of  the  skin  triangle,  A,  so  that  its  mucous 
surface  is  outward,  is  represented  in  the  figure  as  it  appears 
after  having  been  freed  by  dissection,  if  necessary,  and 
turned  down,  leaving  its  raw  surface  out.  The  mucous 
membrane  is  then  slit  up  to  the  corona  at  D,  as  usual, 
after  cutting  away  its  triangle,  and  the  point  A  is  stitched 
last  to  D,  B  to  E,  C  to  F,  and  the  remainder  of  the  edge 
as  usual. 

The  only  objection  to  be  made  to  this  device  is  that  it 
sacrifices  the  liberating  longitudinal  incision  of  the  skin,  and 
Dr.  Keyes2  has  met  this  by  taking  the  triangular  flap  from 
the  mucous  membrane  instead  of  from  the  skin.  He  cuts 
off  the  prepuce  by  a  straight  incision,  and  divides  the  skin 
along  the  dorsum  as  before ;  and  then,  instead  of  splitting 


1  Oral  communication,  1870. 


2  Oral  communication,  1870. 


SPECIAL  OPERATIONS. 


493 


the  mucous  membrane  in  the  same  manner  (Fig.  242,  BD), 
he  makes  a  Y-shaped  incision  (Fig.  245,  BDC),  and  removes 
the  anterior  strip  of  mucous  mem- 
brane by  continuing  the  incision  from 
C  and  D  around  to  the  frseuum.  The 
point  DBC  is  then  reflected,  fitted 
into  the  triangular  gap  G  E  F  left 
by  the  longitudinal  incision  in  the 
skin  and  the  rounding  of  its  corners, 
and  the  edges  are  united  by  sutures, 
as  before. 

If  broad  adhesions  exist  between 
the  glans  and  prepuce,  and  it  is  feared 
that  the  raw  surfaces  left  by  their 
division  will  reunite,  all  the  mucous 
membrane  may  be  removed,  except  a 

ring  about  one-eighth  of  an  inch  wide  adjoining  the  corona; 
the  skin  is  then  drawn  forward,  and  united  to  the  narrow 
ring  of  mucous  membrane.  The  raw  surface  on  the  glans, 
having  nothing  to  adhere  to,  cicatrizes  naturally. 


Circumcision.     Keyes. 


PARAPHIMOSIS. 

A  description  of  the  methods  of  reduction  by  taxis  or  by 
compression  of  the  engorged  prepuce  and  gland  does  not  lie 
within  the  proposed  scope  of  this  work,  and  the  operation 
of  division  of  the  constricting  band  hardly  needs  to  be 
described,  for  it  consists  simply  in  dividing  the  band  from 
without  inward  at  one  or  more  points,  until  the  constriction 
is  sufficiently  relieved  to  allow  the  prepuce  to  be  drawn  for- 
ward. It  is  well  to  make  the  first  incision  in  the  median 
dorsal  line  so  as  to  profit  by  it  afterward,  if  an  operation 
for  phimosis  is  considered  necessary.  If  inflammatory  ad- 
hesions have  formed  along  the  line  of  the  constriction,  forcible 
attempts  to  reduce  the  paraphimosis  should  not  be  made, 
but,  after  division  of  the  band,  the  parts  should  simply  be 
dressed  with  cold  and  soothing  lotions. 


22 


491  OPERA  TIVE  S  UB  GEE  Y. 


DIVISION    OF   THE    FPwENUM. 

Verneuil1  employs  the  following  method  :  He  makes  the 
fneuum  tense,  transfixes  it  close  to  its  attachment  to  the 
glans  with  a  narrow  bistoury  or  tenotome  held  with  its  side 
parallel  to  the  surface  of  the  penis,  and  cuts  out  backward, 
making  a  triangular  flap  nearly  half  an  inch  long,  with  its 
apex  directed  backward.  The  liberated  glans  is  drawn 
forward,  the  flap  disappears,  and  the  edges  of  the  wound, 
which  assumes  the  shape  of  a  lozenge,  are  united  by  sutures. 

EPISPADIAS. 

The  deformity  known  as  epispadias  is  characterized  by 
fissure  of  the  roof  of  the  urethra.  In  its  complete  form  it 
is  associated  with  separation  of  the  symphysis  pubis,  and 
often  with  exstrophy  of  the  bladder,  in  which  case  its  treat- 
ment is  subordinate  to  that  of  the  more  important  defect 
(q.  v.).  In  its  slightest  degree  it  is  confined  to  a  fissure 
occupying  the  dorsal  portion  of  the  glans  penis,  and  extend- 
ing from  the  meatus  to  the  corona  (epispadias  balanique). 
The  existence  of  this  form  has  been  denied,  but  Verneuil2 
reports  two  cases,  in  neither  of  which  did  the  malformation 
cause  any  disturbance  of  function.  In  the  more  important 
varieties  the  urethra  lies  above  the  corpora  cavernosa  in- 
stead of  below  them,  and  is  open  on  the  roof  from  its  an- 
terior extremity  nearly  to  the  bladder ;  the  glans  is  fairly 
developed,  and  may  be  grooved  more  or  less  deeply  along 
its  dorsum,  while  the  rest  of  the  corpus  spongiosum  is 
represented  by  a  thin  layer  of  erectile  tissue  under  the 
urethra.  There  is  sometimes  partial  or  complete  inconti- 
nence of  urine,  and  the  operative  indication  is  to  supply  a 
channel  through  which  the  urine  can  be  conducted  without 
dribbling  to  a  urinal. 

NSlaton's  Method.  The  prepuce  is  drawn  downward  and 
forward  by  means  of  a  ligature  passed  through  it,  and  held 
in  this  position  during  the  operation.     An  incision  is  then 

1  Chimrgle  JU-paratrice,  1887,  p.  730.  -  Loc.  cit.,  p.  718. 


SPECIAL  OPERATIONS. 


495 


made  along  each  side  of  the  urethral  gutter  at  the  junction 
of  the  skin  and  raucous  membrane,  beginning  at  the  prepuce 
and  ending  at  the  abdominal  wall.  The  external  lip  of 
each  incision  is  dissected  up  for  about  one  sixth  of  an  inch, 
forming  a  flap  on  each  side  continuous  with  the  skin  ;  the 
inner  lip  of  each  incision  is  also  slightly  loosened.  The 
flaps  must  be  made  as  thick  as  possible. 

A  third  flap  is  then  marked  out  upon  the  abdominal 
wall,  immediately  above  the  urethral  orifice  leading  to  the 
bladder,  by  two  vertical  incisions  united  at  their  upper 
ends  by  a  transverse  one ;  it  should  be  as  broad  as,  and  a 


Fig.  246. 


Epispadias.  Nelaton's  operation.  A.  Abdominal  flap.  B.  Urethral  infundi- 
bulum.  C,  C.  Lateral  incisions  at  junction  of  skin  and  mucous  membrane.  F, 
F.  Scrotal  incisions  circumscribing  6,  the  scrotal  flap. 

little  longer  than,  the  penis,  dissected  from  above  down- 
ward to  its  base,  which  corresponds  to  the  interpubic  liga- 
ment, and  then  reversed,  its  cutaneous  surface  inward,  and 
its  sides  made  fast  by  sutures  to  the  inner  lips  of  the  in- 
cision on  the  penis,  care  being  taken  to  make  the  contact 
as  broad  as  possible.  Demarquay1  and  Dolbeau2  preferred 
to  make  the  flap  by  prolonging  the  first  two  incisions  up 


1  Maladies  Chirurgicales  du  Penis.  1877,  p.  623. 

2  De  l'Epispadias,  Paris,  1861.    Planche  IV.,  Fig.  I. 


496 


OPERATIVE  SURGERY. 


the  abdomen,  thinking  that  the  continuity  of  the  incisions 
upon  the  abdomen  and  penis  would  increase  the  chances  of 
success  (Fig.  246,  C  C). 

In  order  to  give  the  abdominal  flap  greater  thickness, 
aud  prevent  its  retraction  during  the  process  of  cicatriza- 
tion, Nelaton  reiuforced  it  by  another  taken  from  the 
scrotum.  This  scrotal  flap  is  limited  by  concentric  curved 
incisions  (Fig.  246,  F  F),  the  upper  one  circumscribing  the 
under  half  of  the  root  of  the  penis  in  the  peno-scrotal  angle, 
the  other  at  a  distance  below  the  first  equal  to  the  length 
of  the  penis,  and  is  left  adherent  at  both  ends.  After  the  flap 
has  been  dissected  up,  the  penis  is  passed  under  it,  bringing 
the  raw  surface  of  the  reversed  abdominal  flap  into  contact 
with  that  of  the  scrotal  flap,  and  the  great  circumference  of 
the  latter  is  fastened  by  three  sutures  to  the  outer  lips  of  the 
two  incisions  made  along  the  sides  of  the  urethral  gutter. 

The  canal  thus  formed  is  very  large,  and  both  Nelaton 
and  Dolbeau  found  it  necessary  to  diminish  its  size  by  ap- 
plying the  actual  cautery  to  its  interior.  The  operation  de- 
vised by  Thiersch  is  generally  deemed  superior. 

Thiersch's  Method.1  This  operation  requires  several 
months  for  its  completion,  since  it  is  composed  of  four  dis- 


A 

Epispadias.  Thiersch's  operation.  1.  The  plans  seen  fiom  ahove.  A,  A.  The 
incision  on  each  side  of  the  gutter  C.  B,  B.  The  freshened  surface.  2.  Trans- 
verse section  of  glans  showing  the  incisions.  3.  The  freshened  surfaces  brought 
together  and  closing  in  the  urethra  U. 

tinct  operations  performed  at  different  times.  In  order  to 
prevent  the  urine  from  coming  into  contact  with  the  raw 
surfaces  of  the  flaps  Thiersch  makes  an  opening  into  the 


1  Are.hiv   fiir  Ueilkunde,  18(i'J,  pp.  20-30,  and  Langenheck's  Archiv,   vol.  xv. 
Part  II.  p.  379. 


SPECIAL  OPERATIONS. 


497 


urethra  through  the  periueum  and  maintains  it  during  the 
entire  period  of  treatment. 

First  Step  (Fig.  247).  Creation  of  the  meatus  and  the 
portion  of  the  canal  occupying  the  glans.  The  surgeon 
makes  a  deep  incision  along  each  side  of  the  urethral  groove 
in  the  glans,  pares  the  surface  of  the  outer  lip  of  each  in- 
cision, brings  the  freshened  surfaces  into  contact,  and  fixes 
them  with  two  or  three  points  of  twisted  suture. 

Second  Step  (Figs.  248,  249).  Creation  of  the  urethra 
along  the  body  of  the  penis.  The  surgeon  makes  an  in- 
cision through  the  skin  aud  subcutaneous  tissue  at  the  edge 


Fig.  248. 


Fig.  249. 


Epispadias.  Thiersch.  Se- 
cond step.  Incisions  limiting 
the  two  lateral  flaps. 


Epispadias.    Thiersch.    Transverse  section  of 
penis,  showing  flaps, 


of  the  urethral  gutter  on  the  right  side,  makes  a  short 
transverse  cut  outward  from  each  end,  and  dissects  up  the 
rectangular  flap  thus  marked  out.  On  the  left  side  he 
makes  a  longitudinal  incision  one  centimetre  external  to 
the  edge  of  the  gutter,  and  a  transverse  incision  from  each 
end.  This  flap  is  dissected  up,  making  it  as  thick  as  possi- 
ble, and  turned  over  so  as  to  form  a  roof  for  the  urethral 
gutter,  its  cutaueous  surface  directed  downward,  its  raw 
surface  upward.  Several  ligatures  are  passed  through  it 
near  its  free  border  and  then  through  the  base  of  the  right- 


498  OPERATIVE  SURGERY. 

hand  flap,  and  the  latter  drawn  across  the  former  so  that 
their  raw  surfaces  are  brought  into  contact  throughout. 
The  free  edge  of  the  right  flap  is  then  fastened  to  the  skin 
forming  the  outer  edge  of  the  incision  on  the  left  side. 

Third  Step.  To  close  the  gap  remaining  between  these 
two  new  portious  of  the  urethra.  A  transverse  incision  is 
made  in  the  prepuce,  the  glans  passed  through  it,  the  bor- 
ders of  the  gap  pared  and  fastened  to  the  edges  of  the  in- 
cision in  the  prepuce. 

Fourth  Step.  To  close  the  posterior  portion  of  the  canal 
or  infundibulum.  The  method  employed  is  similar  to  that 
used  in  the  second  step  of  the  operation,  the  flaps  being 
taken  from  the  groins.  The  left  flap  has  the  form  of  an 
isosceles  triangle,  and  its  base  occupies  the  left  half  of  the 
upper  semi-circumference  of  the  openiug  ;  it  is  turned  over 
so  that  its  cutaneous  surface  is  directed  downward,  and  its 
free  border  is  united  to  the  freshened  posterior  edge  of  the 
roof  of  the  new  urethra.  The  other  flap  is  quadrilateral,  its 
base  corresponds  to  the  right  inguinal  ring,  and  it  is  drawn 
over  the  first  one  so  that  their  raw  surfaces  are  brought  into 
contact  and  fastened  together  with  sutures. 

Finally,  the  fistula  established  in  the  perineum  is  closed. 


HYPOSPADIAS. 

The  deformity  known  as  hypospadias  is  characterized  by 
a  congenital  abnormal  opening  of  the  urethra  upon  the 
under  surface  of  the  penis.  Sometimes  the  urethra  ends  at 
the  abnormal  opening,  sometimes  it  is  continued  more  or 
less  imperfectly  beyond  it  either  in  the  form  of  a  tube, 
which  is  usually  imperforate  at  one  or  two  points,  or  in  that 
of  a  gutter.  The  varieties  of  hypospadias  are  usually 
classified  in  three  groups,  the  balanitic,  penile,  and  scrotal, 
according  as  the  abnormal  opening  is  found  at  a  point  in 
the  urethra  corresponding  to  the  glans,  the  pendulous  por- 
tion of  the  penis,  or  the  scrotum.  The  balanitic  is  the  most 
frequent  and  least  important,  and  the  penile  is  less  frequent 
and  less  important  than  the  scrotal.  The  defect  never  ex- 
tends further  back  than  the  bulb  of  the  urethra,  and  conse- 
quently never  causes  incontinence  of  urine.     In  the  scrotal 


SPECIAL  OPERATIONS.  499 

and  in  some  of  the  penile  varieties  the  anterior  portion  of 
the  urethra  forms  a  tense  fibrous  cord  binding  down  the 
glans,  curving  the  body  of  the  penis  upward,  and  prevent- 
ing its  erection. 

In  the  balanitic  variety,  when  the  anterior  portion  of 
the  urethra  exists  in  the  form  of  a  gutter,  no  treatment  is 
required  unless  the  opening  is  too  small.  The  slight  defi- 
ciency in  length  involves  no  loss  of  function,  and  attempts 
to  reconstitute  the  defective  portion  of  the  canal  by  some 
plastic  operation  usually  fail.  In  fact,  if  the  canal  exists 
between  the  meatus  and  the  abnormal  opening,  it  is  better 
to  slit  it  up  than  to  try  to  close  the  latter. 

The  scrotal  variety  is  considered  irremediable,  and  has 
never  been  the  subject  of  surgical  interference.  In  it  the 
scrotum  is  bifid,  the  penis  usually  very  small,  and  the 
urethral  orifice  at  the  bottom  of  an  infundibulum  resem- 
bling a  vulva.  Individuals  thus  deformed  have  often  been 
mistaken  for  hermaphrodites  and  sometimes  for  females. 

In  the  penile  variety,  when  the  anterior  portion  of  the 
urethra  is  normal,  the  opening  may  be  closed  by  freshening 
the  surface  about  its  edge  and  covering  it  with  a  flap  taken 
from  the  adjoining  skin.  When  the  anterior  portion  exists 
only  in  the  form  of  a  more  or  less  shallow  groove,  it  may 
be  transformed  into  a  complete  canal  by  one  of  the  methods 
of  urethroplasty  hereinafter  described.  The  two  other 
modes  of  operating,  urethroraphy  and  perforation,  have  now 
been  discarded  ;  in  the  former  the  edges  of  the  groove  were 
pared  and  brought  together  with  sutures,  in  the  latter  a 
trocar  was  passed  along  through  the  tissues  of  the  uuder 
side  of  the  penis  from  the  extremity  of  the  glans  to  the 
abnormal  opening  of  the  urethra,  and  the  route  thus  created 
kept  open  by  the  frequent  passage  of  sounds. 

If  the  penis  is  incurvated  it  must  be  straightened  as  a 
preliminary  to  any  operation.  To  accomplish  this  it  is  not 
sufficient  to  divide  only  the  fibrous  band  on  its  under  sur- 
face, for  the  retraction  is  partly  maintained  by  the  short- 
ness of  the  inferior  portion  of  the  sheaths  of  the  corpora 
cavernosa  and  the  septum  between  them.  If  the  skin  on 
the  under  surface  is  flexible  enough  to  allow  the  penis  to 
be  straightened  after  the  internal  bands  have  been  divided, 
this  division  may  be  madejsubcutaneously,  following  the. 


500  OPERATIVE  SURGERY. 

example  of  Bouissou,  by  introducing  a  tenotome  and  press- 
ing its  edge  against  the  sheath  of  the  corpora  cavernosa 
and  the  septum  while  the  glans  is  drawn  steadily  away 
from  the  scrotum.  Ordinarily,  however,  this  is  not  possi- 
ble, and  one  or  two  transverse  incisions  one  centimetre 
long  must  be  made  through  the  skin  and  deeper  parts. 
By  the  straightening  of  the  penis  these  transverse  incisions 
are  transformed  into  longitudinal  ones,  and  their  sides  are 
then  drawn  together  by  sutures.  Several  months  must 
then  be  allowed  to  elapse  before  the  subsequent  plastic 
operation  is  undertaken,  in  order  that  the  cicatrix  may  be- 
come perfectly  soft  and  attain  its  full  vitality. 

In  the  earlier  operations  of  urethroplasty  the  floor  of  the 
urethra  was  formed  by  a  long  narrow  vertical  flap  taken 
from  the  scrotum,  its  base  adjoining  the  orifice  of  the  urethra, 
and  its  borders  fastened  to  the  edges  of  two  longitudinal 
incisions  on  the  under  side  of  the  penis.  In  short,  the 
method  resembled  that  already  described  as  employed  by 
Nelaton  for  the  relief  of  epispadias,  even  to  the  reinforce- 
ment of  the  flap  by  a  transverse  one  taken  from  the  skin 
above  the  root  of  the  penis.  The  results  of  these  attempts 
were  so  unsatisfactory  that  when  Nelaton  was  consulted, 
in  1872,  concerning  a  patient  affected  with  hypospadias,  he 
advised  that  nothing  should  be  done,  saying  that  he  had 
made  many  canals  through  which  the  urine  was  carried  to 
the  end  of  the  penis,  but  they  interfered  with  erection,  and 
did  not  facilitate  fecundation.1  The  surgeon  who  received 
this  advice,  Theophile  Auger,  thereupon  devised  another 
method,  ignorant  that  a  similar  one  had  been  employed 
shortly  before  by  Thiersch  in  epispadias  and  by  Scymanow- 
ski  for  urethral  fistula,  and,  having  put  it  into  execution, 
obtained  an  excellent  result. 

TliSophile  Anger's  Method.  In  this  case  the  urethral 
opening  was  at  the  peno-scrotal  angle,  the  anterior  portion 
of  the  canal  was  entirely  lacking,  and  the  penis  was  so 
curved  that  the  extremity  of  the  glans  was  not  more  than 
half  an  inch  from  the  opening.  The  penis  was  first  straight- 
ened  by  two  short  transverse  incisions  carried  to  such  a 

1  ThC-ophile  Anger  in  Hull,  do  la  Soc.  de  Chirurgie,  n6ance  du  21  Jaiivier,  1874 


SPECIAL  OPERATIONS. 


501 


depth  that  the  corpora  cavernosa  were  exposed  at  the  bottom 
of  the  wound;  the  bleeding  was  slight,  and  the  wound 
healed  promptly.  The  plastic  operation  was  performed 
nearly  four  mouths  afterward,  and  was  only  partially  suc- 
cessful, the  posterior  portion  of  the  flap  disappearing  by 
absorption.  A  second  operation,  six  months  later,  was  en- 
tirely successful,  and  the  condition  of  the  parts,  when  the 
patient  was  shown  to  the  Societe  de  Chirurgie  five  months 
afterward,  was  entirely  satisfactory  ;  the  tissues  were  supple, 
there  was  no  stricture  in  the  canal,  and  erection  was  per- 
fect, except  for  a  very  slight  incurvation  downward. 

Fig,  250. 


Hypospadias.    Theophile  Anger's  method. 


The  first  plastic  operation  was  as  follows  :  An  incision, 
extending  from  theglans  to  the  scrotum,  was  made  through 
the  skin  on  the  left  side  parallel  to  the  mediau  line  and  one 
and  a  half  centimetres  from  it,  and  from  each  extremity  of 
this  an  oblique  incision  was  carried  to  the  median  line,  the 
posterior  one  ending  on  the  scrotum  just  behind  the  urethral 
opening  (Fig.  250).     The  cutaneous  flap  circumscribed  by 

22* 


502  OPERATIVE  SURGERY. 

these  three  incisions  was  dissected  np  so  that  it  could  be 
turned  back  with  its  epidermic  surface  directed  inward,  and 
thus  constitute  the  floor  of  the  new  canal.  A  second  longi- 
tudinal incision  was  then  made  a  little  to  the  right  of  the 
median  line,  parallel  to  and  as  long  as  the  first,  a  trausverse 
incision  one  and  a  half  to  two  centimetres  long  carried  out- 
ward from  each  end  of  it,  and  the  flap  thus  circumscribed 
dissected  up. 

A  sound  was  then  introduced  into  the  urethra,  the  first 
flap  drawn  back  over  it,  and  six  sutures  placed  close  to  its 
free  longitudinal  border ;  the  two  ends  of  each  suture  were 
then  attached  to  a  needle  and  carried  through  the  base  of 
the  second  flap  from  within  outward,  as  shown  in  the  figure, 
drawn  tight,  and  fixed  by  pinching  a  tube  of  lead  upon 
them.  Finally,  the  second  flap  was  drawn  over  the  first, 
and  its  edge  made  fast  to  the  outer  lip  of  the  first  incision, 
thus  covering  in  all  the  raw  surface. 

Anger  tied  in  the  catheter  and  left  it  for  several  days, 
but  admits  that  this  was  a  mistake.  When  he  repeated  the 
operation  he  left  the  catheter  in  for  only  twenty-four  hours, 
and  then  reintroduced  it  only  when  the  urine  had  to  be 
drawn  off. 

Duplay's  Method.  The  operation  has  three  steps  or 
stages.  In  the  first,  the  penis  is  straightened  and  a  meatus 
made ;  in  the  second,  the  portion  of  the  urethra  which  is 
lacking  is  restored  ;  and,  in  the  third,  this  new  portion  is 
united  to  that  which  previously  existed. 

First  Step.  The  penis  is  straightened  by  transverse  or 
subcutaneous  incisions  as  before  described,  and  the  meatus 
made  by  paring  a  strip  of  the  surface  of  the  glans  on  each 
side  of  the  groove  representing  the  urethra,  and  bringing 
them  together  with  one  or  two  points  of  twisted  suture  over 
a  piece  of  gum  catheter  placed  in  the  groove.  If  necessary, 
the  groove  may  be  deepened  by  one  or  two  longitudinal  in- 
cisions on  its  floor  (roof  of  the  urethra). 

Second  Step.  Two  longitudinal  incisions,  extending  from 
the  glans  nearly  to  the  abnormal  urethral  opening,  are  made, 
one  on  each  side  of  the  median  line,  at  a  distance  from  each 
other  equal  to  the  circumference  to  be  given  to  the  new 
urethra;  and  from  each  end  of  these  a  short  transverse  in- 
cision  is  made  toward,  but  not  quite  to,  the  median  line 


SPECIAL  OPERATIONS. 


503 


(Fig.  251,  A).  The  rectangular  flaps  thus  circumscribed 
are  dissected  up  toward  the  median  line,  turned  back  over 
a  gum  catheter,  and  their  free  borders  fastened  together 
with  sutures  (Fig.  25 1 ,  B  and  C).  The  outer  lips  of  the 
two  incisions  are  then  loosened  sufficiently  by  dissection  to 
allow  them  to  be  drawn  over  the  others  and  fastened  to- 
gether in  the  median  line  with  interrupted  or  twisted  sutures. 


Fig.  251. 


! 
Hypospadias.    Duplay's  method. 

Care  must  be  taken  to  attach  the  anterior  ends  of  all  four 
flaps  to  the  pared  surface  of  the  glans,  so  that  the  new 
urethra  may  be  continuous  with  the  piece  previously  made. 
Third  Step.  To  close  the  gap  between  the  termination 
of  the  old  and  the  beginning  of  the  new  portions  of  the 
urethra,  Duplay  freshened  the  edges  and  brought  them  to- 
gether with  double  rows  of  sutures. 


URETHRAL    FISTULA. 


Urethral  fistula,  as  a  rule,  are  more  difficult  to  close  the 
further  they  are  from  the  bladder.  Those  occupying  the 
perineum  and  scrotum  are  long,  pass  through  thick  tissues, 
and  will  usually  heal  spontaneously  if  the  full  calibre  of  the 
urethra  iu  front  of  them  is  maintained.  Occasionally  it 
becomes  necessary  to  freshen  their  sides  with  a  knife, 
caustics,  or  cautery. 


504  OPERA  TIVE  S  UE  OEB  Y. 

Fistulse  occupying  the  pendulous  portion  of  the  penis 
have  but  little  tendency  to  close  spontaneously,  unless  they 
are  recent  and  small ;  the  distance  between  the  mucous  and 
cutaneous  surfaces  is  so  short  that  the  walls  of  the  fistula 
cicatrize  promptly  without  uniting,  and  that  renders  a  spon- 
taneous cure  practically  impossible.  Operations  undertaken 
for  the  purpose  of  closing  them,  exclusive  of  simple  cauteriz- 
ation, are  divided  iuto  two  classes,  urethroraphy  and  urethro- 
plasty. In  the  former,  the  sides  of  the  fistula  are  pared 
and  brought  together  in  the  median  line;  in  the  latter,  the 
loss  of  substance  is  made  good  by  the  transfer  of  cutaneous 
flaps. 

It  has  always  been  held  that  the  principal  obstacle  to  the 
closure  of  a  fistula  is  the  frequent  passage  of  urine  through 
it,  and  although  this  has  been  occasionally  questioned,  espe- 
cially with  reference  to  normal,  unaltered  urine,  it  is  still 
considered  one  of  the  principal  indications  to  prevent  this 
passage.  The  choice  lies  between  three  methods  :  1st.  In- 
troducing a  catheter  and  drawing  off  the  urine  as  often  as 
it  becomes  necessary  to  empty  the  bladder  ;  2d,  tying  in  a 
catheter  ;  3d,  establishing  a  free  passage  for  the  urine  at 
some  point  on  the  proximal  side  of  the  fistula.  Each 
method  is  open  to  serious  objections;  the  frequent  passage 
of  the  catheter  is  calculated  to  disturb  the  adjustment  of  the 
flaps,  stretch  the  sutures,  and  irritate  the  urethra ;  and, 
moreover,  a  small  quantity  of  urine  is  sure  to  escape  through 
the  canal  beside  or  behind  it.  A  catheter  retained  in  the 
urethra  for  several  days  is  even  worse  ;  as  Ducamp1  pointed 
out  more  than  fifty  years  ago,  it  violates  the  two  conditions 
necessary  to  the  cicatrization  of  every  wound,  moderate 
degree  of  inflammation  and  of  humidity,  by  irritating  the 
canal,  provoking  an  excessive  flow  of  mucus,  and  acting 
upon  the  wound  itself  as  a  pea  docs  in  an  issue.  After  two 
or  three  days  at  the  latest  it  not  only  fails  to  remove  the 
urine  as  fast  as  it  collects  in  the  bladder,  but  actually 
favors  its  escape  alongside  and  through  the  wound.  It 
excites  cystitis  of  the  vesical  neck,  and  sooner  or  later  gives 
rise  to  the  complex  of  symptoms  known  as  urinary  fever. 
In  short,  it  is  not  only  inefficient  after  the  first  day  or  two, 

1  Trait6  des  K6tentiou«  d'Urine,  1825,  p.  237  ;  quoted  by  Verneuil. 


SPECIAL  OPERATIONS.  505 

but  is  positively  harmful.  The  objections  to  the  third 
method,  unless  perineal  fistula  exist  and  can  be  sufficiently 
enlarged,  are  that  as  usually  practised  it  involves  a  consider- 
able wound  in  the  perineum,  which  may  itself  give  rise  to  a 
fistula  more  obnoxious  than  that  which  it  is  designed  to 
cure,  and  that  by  destroying  the  integrity  of  the  spongy 
tissue  of  the  bulb  it  may  cause  dribbling  and  imperfect 
ejaculation  of  the  last  of  the  urine. 

Urethroraphy.  This  term  is  applied  to  the  simple  ap- 
proximation of  the  sides  of  a  fistula  after  they  have  been 
pared.  Verneuil1  considers  the  method  applicable  to  all 
circular  fistula?  not  more  than  one-fifth  of  an  inch  in  diam- 
eter if  the  surrounding  tissues  are  thick,  and  also  to  ob- 
long fistula?  of  much  greater  size  when  their  long  axis  is  in 
the  median  line  and  their  sides  can  be  easily  brought 
together.  He  thinks  the  numerous  failures  which  have  fol- 
lowed the  use  of  the  operation  have  been  caused  by  a  lack 
of  attention  to  details,  and  he  suggests  that  the  paring  of 
the  edges  should  be  oblique  so  as  to  give  the  fistula  the  form 
of  a  funnel  with  its  apex  at  the  opening  into  the  urethra, 
the  mucous  membrane  of  which  should  not  be  included  in 
the  paring.  Fine  metallic  sutures  should  be  used,  applied 
at  short  intervals,  not  penetrating  to  the  canal  of  the  urethra, 
and  tied  over  a  leaden  plate  on  the  surface.  The  line  of 
reunion  should  be  longitudinal,  not  transverse,  and  if  pri- 
mary union  is  not  obtained  the  sutures  should  be  retained 
to  favor  secondary  union.  During  the  operation  a  sound 
should  be  kept  in  the  urethra  in  order  that  the  canal  may 
have  its  full  size. 

Urethroplasty.  The  methods  that  have  been  suggested 
and  employed  have  been  very  numerous,  but  most  of  them 
count  more  failures  than  successes.  This  is  especially  true 
of  those  by  which  longitudinal  or  transverse  flaps  have  been 
dissected  up  on  opposite  sides  of  the  fistula,  and  brought 
together  by  their  edges  across  its  centre,  for  the  tissues  are 
usually  too  thin  to  afford  a  sufficiently  broad  surface  of  coap- 
tation, and  the  urine  finds  its  way  at  once  through  the 
wound.     It  has  been  proposed  to  overcome  the  latter  ob- 

1  Chirurgie  Reparatrice,  p.  696. 


506 


OPERA  TIVE  S  UR  GER  Y. 


stacle  to  union  by  passing  a  piece  of  thin  India-rubber 
under  the  flaps  (Fig.  252),  but  it  is  doubtful  if  the  presence 
of  the  foreign  body  would  not  have  a  more  unfavorable 
effect  upon  the  thin,  delicate  flaps  than  the  urine  which  it 
is  designed  to  keep  away. 


Fig.  252. 


Fig.  253. 


Urethroplasty. 


Urethroplasty.    Nelaton. 


Xr/aton's  Method.  Nelaton  pared  the  edges  of  the  fistula 
and  dissected  up  the  skin  subcutaneously  for  about  au  inch 
around  it  by  entering  the  knife  through  a  short  transverse 
incision  below  it  (Fig.  253).  The  skin  thus  liberated  was 
pinched  up  in  a  longitudinal  fold  along  the  median  line,  and 
fixed  in  this  position  by  twisted  or  quilted  sutures. 

Reybard  made  the  dissection  through  the  fistula,  thus 
avoiding  the  transverse  incision  of  the  skin.  Dicffenbach 
and  Before  employed  a  similar  method,  but  instead  of  dis- 
secting up  the  skin  subcutaneously  they  raised  two  longitu- 
dinal or  transverse  flaps  and  fastened  them  together  by 
their  raw  and  under  surfaces  (not  edges)  in  the  centre,  the 
former  passing  his  sutures  through  a  leather  splint  on  each 
side,  the  latter  applying  them  in  three  rows,  one  above  the 
other. 


SPECIAL  OPERATIONS.  507 

Delpech  and  Alliot  dissected  up  a  single  flap,  drew  it 
entirely  across  the  fistula,  and  fastened  it  to  a  raw  surface 
prepared  upon  the  opposite  side. 

Sir  Astley  Cooper  cut  away  the  skin  iu  such  a  manner 
as  to  leave  a  raw  surface  of  quadrilateral  form  with  the  fis- 
tula in  its  centre,  and  then  covered  it  with  a  flap  of  the 
same  shape,  taken  from  the  scrotum  by  the  Indian  method 
of  autoplasty. 

Arlaud1  obtained  a  complete  success  in  a  remarkable 
case,  where  the  urethra  had  been  completely  divided  just 
in  front  of  the  peuo-scrotal  angle,  and  its  two  cut  ends 
were  nearly  an  inch  apart,  by  adapting  a  method  previously 
employed  by  Roux  to  close  a  fistula  in  the  trachea.  The 
principle  is  the  same  as  iu  Delpech's  method,  the  difference 
iu  detail  being  that  two  flaps  are  used  instead  of  only  one ; 
the  second  one,  that  which  has  its  cutaneous  surface  pared, 
being  drawn  under  the  first. 

Two  transverse  flaps,  one  in  front  of  the  fistula,  the  other 
behind  it,  were  marked  out  by  longitudinal  incisions  four 
centimetres  apart;  the  anterior  one  was  dissected  up  for  a 
distance  of  two  centimetres  toward  the  glaus,  and  the  pos- 
terior one  dissected  back  over  the  scrotum,  until  it  could  be 
easily  drawn  forward  far  enough  to  cover  the  fistula  entirely. 
The  anterior  portion  of  the  cutaneous  surface  of  the  second 
(scrotal)  flap  was  then  thoroughly  pared,  the  flap  drawn 
forward  so  as  to  cover  the  fistula,  and  the  anterior  flap 
drawn  back  over  the  other  and  fastened  there  by  four  points 
of  twisted  suture. 

Sedillot  dissected  up  a  small  flap  on  each  side,  its  base 
adjoining  the  edge  of  the  fistula,  its  free  border  directed 
outward,  reversed  and  united  them  by  their  free  borders  in 
the  median  line  (their  epithelial  surfaces  directed  inward), 
and  brought  the  sutures  out  through  the  meatus.  The  raw 
surface  of  the  flaps  was  then  covered  by  a  third  flap  trans- 
ferred by  the  Indian  method,  or  by  sliding. 

Rigaud  closed  a  large  fistula  at  the  peno-scrotal  angle  by 
the  method  already  described  as  Nelatou's  method  of  treat- 
ing epispadias.     He  took  a  quadrilateral  mediau  flap  from 

1  Bull,  de  la  SociOto  de  Chirurgie,  1857.  p.  550,  and  Verneuil's  Chirurgie  Ke- 
paratrice,  p.  654. 


508  OPERATIVE  SURGERY. 

the  scrotum,  its  base  adjoining  the  fistula,  turned  it  forward 
over  the  fistula,  and  covered  its  raw  surface  with  two  flaps 
taken  from  the  sides  and  drawn  together  to  meet  in  the 
median  line. 

Theophile  Anger  has  likewise  proposed  to  close  urethral 
fistula?  by  the  method  he  employed  so  successfully  in  a  case 
of  hypospadias  ;  and 

Scymanowski1  reports  a  success  obtained  by  a  method 
which  differed  but  slightly  from  Anger's.  He  made  the 
flaps  much  longer  than  the  fistula,  and  freshened  the  cutane- 
ous surface  of  the  reversed  flap  by  blistering  it,  so  that  it 
could  unite  with  the  raw  surface  upon  which  it  was  laid. 

Dr.  McBurney,  by  the  use  of  methods  similar  to  the  last 
named,  has  obtained  a  number  of  brilliant  succeses  in  ure- 
thral fistula  and  hypospadias ;  several  of  the  cases  are  re- 
ported in  the  proceedings  of  the  New  York  Surgical  Society 
between  1881  and  1884.  In  cases  in  which  previous  opera- 
tions had  failed  and  had  left  cicatricial  tissue  about  the  open- 
ing he  sought  to  close,  he  first  removed  the  cicatricial  tissue 
and  supplied  its  place  with  flaps  taken  from  the  adjoining 
skin.  To  close  the  openings  he  used  flaps  similar  to  Anger's 
(Fig.  250),  leaving  the  epidermis  upon  the  surface  of  the 
one  first  turned  in  over  an  area  corresponding  exactly  to  the 
opening,  and  freshening  with  the  knife  all  the  remaining 
portion  of  its  surface.  He  also  dissected  up  for  a  line  or 
two  the  anterior  edge  of  the  central  unfreshened  portion 
and  tucked  it  under  the  freshened  anterior  margin  of  the 
opening. 

INTERNAL    URETHROTOMY. 

Every  antiseptic  precaution  is  necessary.  A  stricture  in 
the  penile  urethra  is  conveniently  divided  under  cocaine 
by  the  Otis  urethratorae  up  to  any  desired  size ;  the  blad- 
der may  then  be  washed  with  a  sterilized  saturated  solution 
of  boric  acid,  about  four  ounces  of  which  arc  left  in.  The 
passage  of  full-sized  sounds  must  be  kept  up  subsequently. 

For  anterior  strictures  too  tight  to  admit  this  urethra- 
tome,  and  for  deep  strictures,  with  the  observance  of  certain 

1  Handbuch  dor  Opcrativen  Chirurgie,  1870. 


SPECIAL  OPERATIONS. 


509 


precautions,  the  instrument  of  Maisonneuve  is  very  useful. 
The  flexible  filiform  bougie  is  passed  through  the  stricture 
and  secured  to  the  staff,  which  then  follows  the  bougie  into 
the  bladder,  and  the  stricture  is  divided  by  slipping  the 
knife  along  the  whole  length  of  the  groove  while  the  penis 
is  drawn  out  on  the  staff  to  straighten  and  render  tense 
the  urethra,  care  being  taken  to  make  the  section  exactly 
in  the  median  line  of  the  roof.  The  knife  is  blunted  on 
its  summit  and  is  supposed  to  divide  only  the  narrowed 

Fig.  254. 


McBurney's  gorget  and  grooved  sound. 


portions  of  the  canal.  After  a  stricture  beyond  four  and  a 
half  inches  from  the  meatus  has  been  cut  in  this  way,  the 
patient  is  placed  in  a  lithotomy  position,  the  perineal  region 
thoroughly  disinfected  and  shaved,  and  a  broadly-grooved 
staff,  about  the  size  of  a  No.  28-30  F.  sound,  is  passed  to 
the  bladder.  It  is  so  held  in  the  mediau  line  by  au  assist- 
ant as  to  make  the  curved  part  of  the  staff  prominent  in 
the  perineum.  McBurney's  gorget  (Fig.  255),  with  the 
knife  protruded,  is  then  plunged  into  the  centre  of  the  peri- 


510  OPERATIVE  SURGERY. 

neiim,  opening  the  membranous  urethra  and  striking  the 
groove  in  the  staff,  into  which  the  gorget  is  pushed,  sheath- 
ing the  knife,  which  is  then  withdrawn,  while  at  the  same 
time,  by  slightly  tilting  the  staff  and  advancing  the  gorget, 
the  latter  slips  into  the  bladder  as  evidenced  by  the  gush 
of  urine.  A  soft  rubber  catheter  is  inserted  into  the  blad- 
der on  the  gorget  through  the  perineal  puncture  and  re- 
tained by  a  silk  suture  through  the  skin,  and  the  gorget 
is  withdrawn.  The  bladder  and  urethra  are  thoroughly 
irrigated  with  a  saturated  solution  of  boric  acid,  and  the 
catheter  connected  with  a  tube  terminating  beneath  the 
surface  of  a  1:60  solution  of  carbolic  acid  in  a  bottle 
under  the  bed.  A  very  slight  dressing  retained  by  a  split 
T-bandage  around  the  catheter  is  sufficient,  and  at  the  end 
of  five  days  a  sound  is  passed  through  the  whole  length  of 
the  urethra  entering  the  bladder  alongside  of  the  catheter, 
which  if  all  goes  well,  is  removed  twenty-four  hours  later, 
and  a  single  antiseptic  pad  placed  on  the  punctured  wound 
in  the  perineum. 

When  the  bladder  and  urine  are  not  extensively  diseased 
and  there  are  no  other  complications,  such  as  multiple 
fistula,  this  method  of  treating  deep  strictures  is  generally 
preferred  to  the  usual  external  urethrotomy. 


EXTERNAL  PERINEAL  URETHROTOMY. 

A.  With  a  Guide.  Prof.  Syme,  who  introduced  this 
operation,  employed  as  a  guide  a  staff,  the  straight  por- 
tion of  which  was  of  full  size,  and  its  curved  portion 
much  smaller  and  grooved  on  the  convexity.  The  change 
.from  the  full  to  the  small  size  was  abrupt,  not  gradual 
(Fig.  256).  This  instrument  has  been  superseded,  in  the 
United  States  at  least,  by  the  tunnelled  instruments  intro- 
duced by  Prof.  Van  Buren,1  which  are  passed  into  the 
bladder  over  a  fine  whalebone  bougie  as  a  guide,  the  beak 
of  the  instrument  being  bridged  over  or  drilled  out  for  a 
distance  of  about  one-quarter  of  an  inch,  so  that  it  can  be 
slipped  over  the  bougie  (Fig.  255).     If  a  Syme's  staff  or 

1  Van  Buren  and  Keyes,  Genito-Urinary  Diseases,  p.  127. 


SPECIAL  OPERATIONS. 


511 


a  tunnelled  catheter  cannot  be  had, 
any  instrument  may  be  used  which 
can  be  got  into  the  bladder,  but  it 
is  a  great  advantage  to  be  able  to 
pass  a  full-sized  instrument  step  by 
step  as  the  stricture  is  divided. 

The  patient  is  placed  in  the  lith- 
otomy position  (dorsal  decubitus, 
thighs  flexed  upon  the  abdomen,1 
ankles  made  fast  to  the  wrist,  the 
perineum  shaved,  the  whalebone 
guide  introduced  into  the  bladder, 
a  tunnelled  silver  catheter  of  full 
size,  grooved    on   the   convexity, 

Fig.  255. 


Fig.  256. 


Syme's  staff  for  perineal  section. 

passed  down  over  it  to  the  stricture 
and  confided  to  an  assistant,  who 
also  draws  the  scrotum  forward 
out  of  the  way.  An  incision,  vary- 
ing in  length  according  to  the  posi- 
tion of  the  stricture,  is  made  in  the 
median  line,  and  the  end  of  the 
catheter  exposed.  If  the  stricture 
is  deeply  placed  the  sides  of  the 
incision  must  now  be  held  apart 
by  means  of  two  stout  ligatures 
passed  through  them,  one  on  each 
side,  while  the  guide  is  carefully 
followed  from  before  backward 
with  short  cautious  strokes  of  the 
knife  in  the  median  line,  and  the 
catheter  pushed  along  as  the  route 


Tunnelled  instrument  and 
whalebone  guide. 


1  A  convenient  method  of  keeping  the  thighs  fixed  is  to  pass  a  stout  cane 
under  the  knee  and  fasten  it  with  a  cord  or  roller  bandage  passed  from  one  end 
around  the  patient's  neck  to  the  other  end.  An  instrument  has  been  specially 
constructed  for  the  purpose  (Fig.  257),  but  a  stout  stick  does  very  well. 


512  OPERATIVE  SURGERY. 

is  opened,  uutil  the  posterior  limit  of  the  stricture  having 
been  passed,  it  slips  into  the  bladder.  Care  must  be  taken 
not  to  divide  the  whalebone  guide  by  a  careless  stroke  of 
the  knife. 

Fig.  257. 


Clover's  crutch,  for  operations  upon  the  perineum. 

If  Syme's  staff  is  used,  the  incisiou  is  carried  down  until 
the  groove  in  the  curve  of  the  staff  can  be  felt  by  the  finger ; 
the  handle  of  the  staff  is  then  grasped  with  the  left  hand, 
the  point  of  a  narrow  bistoury  passed  into  the  groove  behind 
the  stricture,  and  the  latter  divided  by  cutting  from  behind 
forward. 

Any  bands  that  are  found  on  the  roof  of  the  urethra 
must  be  divided,  and  a  full-sized  steel  sound  passed  to 
make  sure  that  the  stricture  has  been  thoroughly  relieved. 

B.  Without  a  Guide.  The  cases  are  very  rare  in  which 
a  filiform  whalebone  bougie  cannot  be  passed  through  a 


SPECIAL  OPERATIONS.  513 

stricture  which  allows  urine  to  pass,  and  consequently  ex- 
ternal urethrotomy  without  a  guide  is  not  ofteu  required. 
The  patient  is  placed  in  the  lithotomy  position,  the  perineum 
shaved,  and  a  full-sized  catheter  passed  down  to  the  stricture 
and  confided  to  an  assistant,  who  also  draws  the  scrotum 
forward,  keeping  its  raphe  exactly  in  the  median  line.  An 
incision,  two  and  a  half  to  three  inches  long,  is  made  in  the 
median  line,  and  the  end  of  the  catheter  exposed  by  open- 
ing the  urethra  one-quarter  of  an  inch  in  front  of  the  stric- 
ture. The  catheter  is  then  partly  withdrawn,  the  sides  of 
the  wound  held  widely  apart  by  means  of  stout  ligatures 
passed  through  them,  and  an  effort  made  to  pass  a  fine 
probe  or  whalebone  bougie  through  the  stricture  from  before 
backward ;  if  the  effort  succeeds,  the  operation  becomes  one 
"  with  a  guide,"  and  is  completed  as  before  described.  If 
the  probe  can  be  passed  for  only  a  short  distance,  a  line  or 
two,  the  tissues  are  divided  upon  it,  and  the  attempt  re- 
newed until  the  canal  behind  the  stricture  is  reached. 

If  these  efforts  fail  entirely,  the  urethra  must  be  sought 
for  behind  the  stricture — a  most  difficult  task  unless  a  peri- 
neal fistula  exists  through  which  a  guide  can  be  passed  into 
the  bladder,  or  unless  this  portion  of  the  urethra  is  dis- 
tended with  urine  and  can  be  punctured  in  the  median  line. 
Van  Buren  and  Keyes1  recommend  that  the  surgeon  should 
feel  for  the  hole  in  the  triangular  ligament,  and  cut  into  it 
through  the  fibrous  mass  by  repeated  strokes  with  the  knife, 
always  in  the  median  line.  Others  prefer  to  pass  the  index 
finger  of  the  left  hand  into  the  rectum,  place  it  against  the 
apex  of  the  prostate,  and  continue  the  dissection  backward 
with  a  view  to  opening  the  urethra  at  that  point.  When 
this  has  been  accomplished,  a  sound  is  passed  from  behind 
forward  to  the  posterior  face  of  the  stricture,  and  the  latter 
divided  as  thoroughly  as  possible  between  the  two  sounds. 

If  the  stricture  lies  in  front  of  the  triangular  ligament, 
the  centre  of  the  arch  of  the  pubes  is  an  invaluable  guide, 
toward  which  the  incisions  should  be  constantly  directed. 

Perineal  Urethrotomy  for  Exploration  of  the  Bladder 
(Thompson).    The  instruments  needed  are  a  median  grooved 

1  Diseases  of  the  Genito-Urinary  Organs  with  Syphilis,  p.  125. 


514  OPERATIVE  SURGERY. 

staff  and  a  long  straight,  narrow-bladed  knife,  with  the  back 
blunt  to  the  point.  Having  placed  the  left  index  fiuger  in 
the  rectum  and  introduced  the  staff,  the  knife  is  introduced, 
edge  upward,  about  three-quarters  of  an  inch  above  the 
anus,  with  or  without  a  small  preliminary  incision  of  the 
skin,  until  the  point  reaches  the  staff  about  the  apex  of  the 
prostate,  where  it  divides  the  urethra  for  half  an  inch,  and 
is  then  drawn  out,  cutting  upward  a  little  in  the  act,  but  so 
as  to  avoid  any  material  division  of  the  bulb.  The  index 
finger  is  then  slowly  passed  into  the  bladder  through  the 
wound  as  the  staff  is  withdrawn,  and  the  interior  of  the 
bladder  explored  with  the  aid  of  firm  pressure  above  the 
pubes  with  the  other  hand. 


EXSTROPHY    OF   THE    BLADDER. 

The  first  operation  for  the  relief  of  this  deformity  was 
performed,  according  to  Gross,  by  Prof.  Paucoast,  of  Phila- 
delphia, in  1858  ;  according  to  Erichsen,  by  Dr.  Daniel 
Ayres,  of  Brooklyn,  in  1859.  The  deformity  is  much  more 
frequent  in  males  than  in  females,  aud  the  operative  indi- 
cation is  to  cover  in  as  much  as  possible  of  the  exposed 
mucous  membrane  and  facilitate  the  adaptation  of  a  urinal 
by  making  the  urine  escape  through  a  comparatively  small 
opening;  for,  as  the  sphincter  cannot  be  restored,  there  will 
always  be  incontinence.  The  method  employed  is  the  same 
as  NSlaton's  for  epispadias :  a  tegumentary  flap  is  raised 
from  the  abdomen  above  the  bladder,  reversed  so  as  to 
cover  the  latter,  and  then  covered  itself  in  turn  by  lateral 
(laps,  one  from  each  side. 

The  first  flap  (Fig.  258)  should  be  square,  its  base  ad- 
joining and  slightly  broader  than  the  upper  margin  of  the 
opening,  its  length  should  be  sufficient  to  cover  in  the 
bladder  completely  when  turned  down  over  it.  A  pyriform 
flap  is  dissected  up  on  each  side,  its  breadth  equal  to  the 
length  of  the  first  flap,  and  its  base  directed  downward  and 
inward,  as  shown  in  Fig.  258,  or  downward  and  outward 
so  as  to  require  less  twisting  and  include  more  of  the  cuta- 
neous branches  coming  from  the  femoral  artery.  These 
two  flaps  are  then  drawn  across  the  reversed  umbilical  flap, 


SPECIAL  OPERATIONS. 


515 


meeting  in  the  median  line,  and  are  fastened  to  each  other 
with  twisted  sutures,  the  pins  including  a  portion  of  the 
thickness  of  the  umbilical  flap  also,  so  as  to  keep  the  raw 
surfaces  in  contact  (Fig.  259). 


Fig.  25S. 


Fig.  259. 


Wood's  operation  for  exstrophy  of  the  bladder. 
Incisions. 


Flaps  in  place. 


The  edges  of  the  gaps  left  by  the  removal  of  the  flaps  are 
drawn  together  as  well  as  possible  with  twisted  and  wire 
sutures,  broad  strips  of  adhesive  plaster  applied  to  give 
support  aud  relieve  tension,  and  the  patient  kept  in  bed  in 
a  sitting  posture  with  the  knees  drawn  up.  The  sutures 
may  be  removed  at  the  end  of  a  week.  Healing  may  be 
hastened  by  using  Thiersch  skin  grafts  on  granulating  sur- 
faces. 

When  the  symphysis  is  absent  Trendelenburg  first  per- 
forms an  operation  to  remedy  the  epispadias.  Later  he 
divides  the  sacro-iliac  synchondrosis  on  each  side  from 
behind  forward,  sufficiently  to  mobilize  the  iliac  bones  and 
allow  the  gap  in  front  to  be  closed  by  pressing  together  the 
sides  of  the  pelvis.  Subsequently  the  margins  of  the 
defect  in  the  soft  parts  are  freshened  and  brought  together 
with  sutures.  This  may  need  to  be  supplemented  by  a 
flap  operation  aud  Thiersch  skin  grafts. 

Czerny,  starting  at  the  edges  of  the  defect,  frees  the 
mucous  membraue  from  the  underlying  parts  and  sutures 
its  margins  together  to  form  a  closed  sac.     Then  this  is 


516  OPERATIVE  SURGERY. 

covered  in  by  two  lateral  flaps,  base  down,  as  in  the  first 
operation  described.  Afterward  the  neck  of  the  bladder 
and  the  freshened  edges  of  the  prostatic  portion  of  the 
urethra  are  brought  together,  and  then  the  epispadias  is 
attended  to. 

A  perfect  result  in  this  condition  is  an  impossibility. 
Even  if  no  fistula  persist  the  sphincter  will  not,  at  the 
best,  be  of  much  value,  and  the  wearing  of  some  sort  of 
urinal  is  a  necessity. 


CATHETERIZATION  (WITH  CURVED  METAL  CATHETER). 

The  obstacles  to  the  passage  of  a  catheter,  exclusive  of 
stricture  and  of  false  passage,  are  found  either  at  the  trian- 
gular ligament  in  the  membranous  or  in  the  prostatic  por- 
tion of  the  urethra.  As  the  fixed  portion  of  the  canal  begins 
anteriorly  at  the  opening  in  the  subpubic  or  triangular  liga- 
ment, the  flaccid  pendulous  portion  in  front  of  this  point 
may  be  carried  aside  if  the  catheter  is  held  improperly,  and 
doubled  upon  itself  in  front  of  the  beak  of  the  instrument, 
thus  forming  a  sort  of  pouch  or  cul-de-sac  which  arrests 
the  progress  of  the  catheter.  This  difficulty  is  overcome 
by  drawiug  the  penis  gently  up  the  shaft  of  the  instrument 
so  as  to  straighten  out  the  portion  of  the  canal  yet  to  be 
traversed,  and  by  keeping  the  beak  in  the  median  line  and 
making  it  follow  the  roof  rather  than  the  floor  of  the 
urethra,  so  as  to  avoid  especially  the  normal  pouch-like 
dilatation  found  on  the  under  side  just  in  front  of  the 
opening  in  the  ligament. 

The  obstacle  in  the  membranous  portion  is  caused  by  the 
spasmodic  contraction  of  the  muscles  which  envelop  this 
part  of  the  canal.  The  nature  of  the  obstruction  is  recog- 
nized by  the  tight  grasp  of  the  instrument  by  the  muscles, 
the  quivering  of  the  fibres  transmitted  through  it  to  the 
hand  of  the  surgeon,  and  by  the  knowledge  of  the  fact  that 
the  instrument  has  reached  this  part  of  the  canal  where 
organic  obstacles  do  not  often  exist.  The  difficulty  is  over- 
come by  making  gentle  pressure  with  the  beak  of  the  ca- 
theter in  tin;  proper  direction,  so  as  to  tire  out  the  muscles. 

The  most  serious  obstacle  is  found  in  the  prostatic  por- 


SPECIAL  OPERATIONS  517 

tion,  aud  is  due  either  to  inflammatory  swelling  of  the  mu- 
cous membrane  or  of  the  gland  (abscess  of  the  prostate),  or, 
much  more  commonly,  to  senile  change  in  the  shape  and 
size  of  this  organ.     A  description  of  the  nature  of 

•  Fir  260 

these  changes  aud  lesions  does  not  come  within  the 
scope  of  this  work,  and  the  reader  is  referred  for 
them  to  special  treatises  upon  the  subject.  It  is 
sufficient  here  to  say  that  in  the  former  case  the 
inflammation  must  be  reduced  or  the  abscess  evacu- 
ated secundum  artem,  or,  failing  this,  the  bladder 
must  be  punctured  above  the  pubes,  or  through 
the  rectum.  In  the  other  case,  catheters  of  different 
curves  should  be  tried,  such  as  Mott's  long  catheter 
of  large  curve,  or  Mercier's  soft,  single  or  double- 
elbowed  catheter  (Fig.  260).  It  is  also  well  to  pass 
the  forefiuger  of  the  left  hand  into  the  rectum  to 
make  sure  that  the  catheter  has  entered  at  the  apex 
of  the  prostate,  aud  that  it  has  not  passed  out  of 
the  canal  into  a  false  passage,  and  to  try  to  lift  its 
beak  over  the  obstacle  by  making  direct  pressure 
upon  the  curve  in  front  of  the  prostate,  while  the 
handle  is  simultaneously  depressed. 

If  these  means  fail,  and  soft  instruments  of  gum 
or  vulcanized  rubber  cannot  be  introduced,  the 
bladder  must  be  punctured. 

Passage  of  the  Catheter.     The    patient    having 
been  brought  to  the  side  of  the  bed  or  placed  upon 
a  lounge,  the  surgeon,  standing  on  one  side,  pre- 
ferably the  left,  separates  the  lips  of  the  meatus 
with  the  thumb  and  forefinger  of  the  left  hand,  in- 
troduces the  beak  of  the  catheter,  previously  well 
warmed  and  oiled,  and  passes  it  down  to  the  peno- 
scrotal augle,  holding  the  shaft  of  the  instrument      Mt 
parallel  to  the  groin.     He  then  sweeps  the  handle       Mer- 
around  to  the  median  line  of  the  abdomen,  keeping       cier's 
it  close  to  the  surface,  draws  the  penis  gently  up  the     ^^eter 
shaft,  and  presses  the  instrument  bodily  downward 
toward  the  feet ;   as  soon  as  the  beak  reaches  the  lower 
border  of  the  symphysis  he  draws  the  scrotum  up  and  presses 
the  catheter  gently  onward,  still  holding  it  parallel  to  the 
body,  aud  then  when  the  beak  has  closely  approached  or 

23 


5 1 8  OPERATIVE  S UBOER  Y. 

engaged  in  the  opening  in  the  triangular  ligament  he  gradu- 
ally raises  the  handle,  brings  it  forward  in  the  median  line, 
and  depresses  it  between  the  thighs.  Failure  to  enter  the 
opening  in  the  triangular  ligament  is  indicated  by  the  bulg- 
ing of  the  curve  of  the  instrument  in  front  of  the  sym- 
physis, its  rebound  when  the  slight  pressure  on  the  handle 
is  removed,  and  the  mobility  of  the  beak  when  the  handle 
is  gently  rotated  about  its  longitudinal  axis. 

As  the  shaft  passes  the  vertical  line  the  root  of  the  penis 
and  the  integument  covering  the  symphysis  should  be 
pressed  down  with  the  palm  of  the  right  hand  laid  broadly 
upon  it,  so  as  to  stretch  the  suspensory  ligament. 


PUNCTURE    OF   THE    BLADDER. 

Above  the  Pubes.  The  only  instrument  required  is  a 
straight,  or,  better,  a  curved  trocar  and  cauula,  the  trocar 
having  a  groove  in  its  side  which  permits  a  small  stream  of 
urine  to  pass  as  soon  as  the  bladder  is  reached.  The  sur- 
geon satisfies  himself  by  percussion  that  the  distended  blad- 
der rises  well  above  the  pubes,  and  then  making  the  skin 
tense  with  the  thumb  and  fingers  of  his  left  hand,  he 
plunges  in  the  trocar  close  above  the  symphysis  pubis  in 
the  median  line,  the  concavity  of  the  instrument  turned 
toward  the  bone. 

Some  surgeons  prefer  to  make  a  preliminary  incision  in 
the  median  line,  and  others  (Holmes)  even  continue  the  use 
of  the  knife  until  the  bladder  can  be  felt  at  the  bottom  of 
the  wound. 

LITHOLAPAXY. 

It  is  the  operation  of  introducing  a  lithotrite  into  the 
bladder  through  the  urethra  and  with  it  crushing  a  stone 
into  fragments,  which  are  then  removed  by  the  wash  bottle 
and  evacuators  represented  in  Fig.  266. 

The  modern  lithotrite  is  a  steel  instrument  consisting  of 
a  straight  shaft  eleven  inches  in  length,  having  at  one  end 
a  "  beak  "  about  an  inch  long  inclined  at  an  angle  of  from 
110°  to  130°,  and  at  the  other  a  cylindrical    roughened 


SPECIAL  OPERATIONS. 


519 


handle  containing  a  screw.  It  is  composed  throughout  of 
two  parts,  one  fitting  accurately  in  a  deep  groove  in  the 
other,  and  having  at  the  handle  a  male  screw  which  can  be 
thrown  into  and  out  of  gear  by  means  of  a  button  upon  the 
other  part.  While  trying  to  catch  a  stone  the  screw  should 
be  out  of  gear,  in  order  that  the  male  blade  may  be  advanced 


and  withdrawn  more  rapidly,  but  when  the  stone  has  been 
fairly  caught  the  button  must  be  pressed  back  and  the 
screw-power  used  to  crush  it. 

Many  different  patterns  have  been  proposed  for  the  beak 


520 


OPERATIVE  SURGERY. 


or  jaws  with  the  view  either  of  securing  the  thorough  pul- 
verization of  the  fragments,  or  of  preventing  the  clogging  of 
the  instrument  by  the  impaction  of  the  mortar-like  detritus 
between  the  jaws.  The  latter  difficulty  can  be  overcome  by 
leaving  the  jaw  of  the  female  blade  entirely  open,  that  is, 
with  a  large  fenestra  extending  from  side  to  side  and  from 
the  extremity  of  the  beak  to  its  angle,  and  by  making  the 
male  blade  long  enough  to  allow  its  jaw  to  be  passed  entirely 
through  the  female  one  and  even  to  project  beyond  its  con- 
vex surface.  In  its  simplest  terms,  then,  the  jaws  should 
consist  of  two  parallel  bars,  one-fourth  of  an  inch  apart, 
between  which  a  third  one,  fitting  loosely  in  the  gap,  can  be 
forced.  Of  course,  the  male  jaw  must  not  be  allowed  to 
project  beyond  the  convex  surface  of  the  female  one  during 
its  passage  through  the  urethra. 

A  small  fenestra  at  the  angle  of  the  beak  will  not  prevent 
clogging,  although  it  may  diminish  it  if  there  is  a  cor- 
responding projection  at  the  heel  of  the  male  jaw,  as  in 

Fig.  263. 


"  Scoop"  lithotrite. 


Fig.  263  ;  and  it  is  open  to  the  very  serious  objection  that 
it  may  lodge  a  sharp  angular  fragment,  which,  projecting 
beyond  its  edges,  will  lacerate  the  neck  of  the  bladder  and 
the  floor  of  the  urethra  during  the  withdrawal  of  the  instru- 
ment. 

The  arrangement  of  open  spaces  in  the  female  jaw  cor- 
responding to  guttered  projections  or  teeth  upon  the  male 
jaw,  as  in  Reliquet's  model,  is  entirely  insufficient  to  prevent 
clogging.  The  detritus  packs  across  the  gaps  and  presents 
;iii  absolute  bar  to  the  closing  of  the  instrument.    Whenever 


SPECIAL  OPERATIONS. 


521 


such  corresponding  teeth  and  spaces  are  used  they  should  be 
cut  to  fit  each  other  very  loosely,  that  is,  with  a  clear  space 
of  at  least  one  millimetre  between  them. 

For  catching  and  crushing  small  fragments  the  "scoop'' 
lithotrite  is  commonly  used  ;  the  jaw  of  its  female  blade 
is  broad  and  shallow,  with  no  fenestra  or  with  only  a  small 
one  at  its  angle.  The  edges  of  both  jaws  should  be  bevelled, 
and  the  male  considerably  narrower 
than  the  female,  so  that  they  maybe 
brought  together  with  the  least  pos- 
sible danger  of  including  a  fold  of 
mucous  membrane  between  them. 

Prof.  Bigelow,1    of  Boston,  re- 
commends   an    instrument   (Figs. 


Fig.  264. 


Bigelow's  lithotrite 


264  aud  265)   combining,  as   he  claims,  the  advantages 
of  the  fenestrated  and  the  scoop  lithotrites.    The  female  jaw 


1  The  American  Journal  of  the  Medical  Sciences,  Jan.  1878. 


522  OPERATIVE  SURGERY 

is  shallow,  so  that  small  fragments  are  easily  caught  and 
crushed  in  it,  and  clogging  is  prevented  by  deep  notches 
opening  outward  on  the  sides  of  the  male  jaw  (Fig.  265), 
and  by  a  small  fenestra  at  the  angle  to  provide  for  the  escape 
of  the  detritus  engaged  in  the  groove  of  the  female  blade. 
He  also  substitutes  for  the  button  on  the  handle  of  Thomp- 
son's lithotrite,  a  mechanism  partly  shown  in  Fig.  264,  by 
which  the  screw  can  be  thrown  into  gear  by  a  turn  of  the 
hand  holding  the  end  of  the  male  blade ;  and,  further, 
curves  the  beak  of  the  instrument  to  facilitate  its  passage 
through  the  prostatic  urethra.  It  must  be  admitted,  how- 
ever, that  with  a  soft,  phosphatic  stone  the  instrument  will 
become  impacted ;  and  when  the  stone  is  large  and  hard 
the  connecting  catch  is  liable  to  be  torn  away.  I  prefer, 
therefore,  the  instrument  recommended  by  Prof.  Keyes 
(Fig.  262) ;  it  cannot  clog,  and  the  lateral  catch  cannot  be 
broken  by  any  force  exerted  through  the  screw. 

Operation.  The  patient  is  anaesthetized  and  placed  upon 
his  back,  with  his  hips  raised  upon  a  firm  pillow  or  cushion 
in  order  that  the  stone  may  gravitate  away  from  the  neck 
of  the  bladder.  If  the  urine  is  turbid,  and  especially  if  it 
is  ammoniacal,  it  should  be  drawn  off  before  the  operation 
and  the  bladder  thoroughly  washed  with  a  borax  solution 
(one  or  two  drachms  to  the  pint),  of  which  from  two  to 
four  ounces  should  be  left  in  the  bladder  to  facilitate  the 
crushing.  The  surgeon,  standing  at  the  patient's  right  side, 
introduces  a  freshly  boiled  lithotrite  after  greasing  the  in- 
strument with  vaseline.  Great  care  must  be  taken  not  to 
depress  the  handle  too  soou,  a  mistake  which  is  likely  to 
be  made  on  account  of  the  apparently  great  depth  to  which 
the  instrument  has  to  penetrate  before  the  bladder  is  reached. 

As  soon  as  the  instrument  has  entered  the  bladder,  it  is 
allowed  to  glide  across  it,  its  shaft  being  held  steadily  in 
one  position,  and  if  the  stone  is  free  it  will  generally  be 
touched  on  the  way.  The  surgeon  then  gently  turns  the 
beak  away  from  the  stone,  withdraws  with  his  right  hand  the 
male  blade  for  a  distance  determined  by  previous  measure- 
ment of  the  stone,  presses  the  jaw  of  the  female  blade 
gently  against  the  floor  and  posterior  wall  of  the  bladder, 
rotates  the  beak  toward  the  stone,  and  closes  the  male  blade 
upon  it.     As  soon  as  the  stone  is  felt  to  be  firmly  caught, 


SPECIAL  OPERATIONS. 


523 


the  beak  is  rotated  back  to  the  vertical  position,  and  the 
screw  thrown  into  gear  by  pressing  back  the  button  on  the 
handle  with  the  thumb  of  either  hand.  The  lithotrite  with 
the  stone  in  its  grasp  is  then  drawn  away  from  the  pos- 
terior wall  and  rotated  to  either  side  to  make  sure  that  the 
mucous  membrane  is  not  caught  between  its  jaws,  and  then, 
grasping  the  cylindrical  handle  firmly  with  his  left  hand, 
the  surgeon  crushes  the  stone  by  turning  the  screw  with  his 
right,  and  continues  this  action  until  the  register  upon  the 
handle  shows  that  the  male  blade  has  been  driven  well 
home.  The  screw  is  then  thrown  out  of  gear,  the  male 
blade  drawn  back,  the  beak  turned  again  toward  the  spot 
where  the  stone  was  caught,  and  the  instrument  closed 
whether  the  fragments  are  felt  or  not,  for  it  may  be  confi- 
dently expected  that  they  will  be  found  there. 


Evacuating-tube  and  washing-bottle. 


After  crushing  the  stone  in  this  manner  several  times  the 
smaller  fragments  are  washed  out  by  the  evacuating  tube 
and  washing-bottle  (Fig.  266)  and  the  lithotrite  reintro- 
duced ;  and  this  alternation  in  the  use  of  the  instruments 
is  continued  until  the  bladder  is  emptied.  This  frequent 
washing  is  important  because  by  the  removal  of  the  smaller 


524  OPERATIVE  SURGERY. 

fragments  it  is  made  easier  to  seize  and  crush  the  larger 
ones. 

The  washing  is  done  as  follows :  The  washing-bottle  is 
filled  with  tepid  water,  then  the  tube  is  introduced,  and  as 
soon  as  the  urine  begins  to  flow  through  it  the  bottle  is 
coupled  to  it.  Or  the  coupling  may  be  done  just  before  the 
tube  has  entered  the  bladder,  and  the  air  in  the  tube  allowed 
to  rise  to  the  top  of  the  bottle,  by  turning  the  stopcock, 
before  the  introduction  is  completed  and  the  washing  is 
begun. 

By  quick  compression  and  relaxation  of  the  rubber  bulb 
the  water  is  rapidly  forced  into  the  bladder  and  drawn  back 
again,  bringing  the  fragments  with  it ;  these  fragments  sink 
to  the  bottom  of  the  bottle  and  are  not  returned  with  the 
returning  stream.  The  amount  of  water  driven  back  and 
forth  at  each  movement  will  vary  with  the  sensitiveness  and 
distensibility  of  the  bladder ;  two  or  three  ounces  are  suffi 
cient  to  wash  effectively.  If  the  curved  tube  is  used,  its 
eye  should  be  in  turn  directed  to  different  quarters  of  the 
bladder ;  if  the  straight  tube  with  a  square  end  is  used,  it 
must  be  passed  just  through  the  neck,  and  its  outer  end 
well  depressed  between  the  thighs. 

At  the  close  of  the  operation  the  surgeon  should  place 
his  ear  upon  the  hypogastrium  and  listen  while  washing,  to 
detect  the  click  against  the  tube  of  any  fragments  that 
may  remain.  This  is  a  much  more  delicate  test  than  the 
use  of  the  searcher. 

LITHOTOMY. 

The  anatomy  of  the  perineum  is  sufficiently  well  shown 
in  Fig.  267  to  render  a  detailed  description  unnecessary. 
It  must  be  remembered,  however,  that  the  distance  between 
the  anus  and  the  bulb  diminishes  with  advancing  years,  and 
that  the  diminution  of  the  distance  is  due  to  an  increase  in 
the  size  of  the  bulb.  The  dangers  incident  to  incision  of 
the  bulb  increase,  therefore,  with  the  difficulty  of  avoiding 
it.  The  dimensions  of  the  prostate  have  been  studied  with 
much  attention,  and  have  been  the  basis  of  many  of  the 
modifications  of  perineal  lithotomy,  for  it  has  been  held, 
mid  still  is  held  by  many,  that  the  incision  should  not  be 


SPECIAL  OPERATIONS. 


525 


carried  beyond  the  limits  of  the  gland.  The  greatest  radius, 
measuring  from  the  urethra,  is  one  inclined  about  30°  back- 
ward and  downward  from  the  transverse  diameter,  and  in 
the  normal  adult  prostate  this  measures  about  three-quar- 


PlG.  267. 


Avtery  of  corpus  cavernosum 
Dorsal  artery  of  penis 


Artery  of  bulb. 

Internal  pudic  artery J| 


Cowpefs  gland. 


A  view  of  the  position  of  the  viscera  at  the  outlet  of  the  pelvis. 


ters  of  an  inch  at  the  largest  part  of  the  gland,  that  which 
adjoins  the  neck  of  the  bladder.  But,  as  the  diameter  of 
the  prostate  diminishes  as  the  distance  from  the  bladder  in- 
creases, an  incision  which  remains  within  its  limits  at  one 
point  may  extend  far  beyond  them  at  another ;  and  this 
fact,  taken  in  connection  with  the  great  variations  in  the 
size  of  the  gland,  indicates  the  futility  of  attempts  to  regu- 
late the  incision  with  mathematical  precision.  Fortunately, 
the  depth  of  the  incision  is  not  a  measure  of  the  size  of  the 

23* 


526 


OPERATIVE  SURGERY. 


stone  which  can  be  safely  removed  through  it,  for  the  nor- 
mal dilatability  of  the  neck  of  the  bladder  and  the  prostatic 
portion  of  the  urethra  (to  a  diameter  of  two  centimetres,  ac- 
cording to  Dolbeau)  is  thought  to  be  considerably  increased 
by  even  slight  incisions.  Dupuytren  thought  the  opening 
in  the  prostate  could  be  greatly  enlarged  by  making  an 
oblique  incision  on  each  side  (bilateral  lithotomy),  but  the 
gain  has  not  proved  so  great  as  was  expected. 


Fig.  268. 


Incision  in  lateral  lithotomy  ;  the  dotted  lines  mark  its  limits.  A.  Vas  deferens. 
B.  Seminal  vesicle.  C.  Continuation  of  the  capsule  or  prostato-peritoneal  liga- 
ment. 


By  reference  to  Figs.  268  and  269,  which  show  the  ex- 
tent of  the  incision  of  the  prostate  and  neck  of  the  bladder 
in  lateral  lithotomy,  it  will  be  seen  that  the  limits  of  the 
prostate  are  exceeded  everywhere,  the  capsule  remaining 
intact,  however,  for  a  distance  of  about  half  an  inch  at  the 
thickest  part  of  the  gland.  The  sulcus  between  the  bladder 
and  the  prostate  is  opened,  and  the  bladder  wall  divided  for 
fully  half  an  iuch  in  the  direction  of  the  orifice  of  the  left 
ureter.  These  figures  are  taken  from  a  dissection  of  a 
cadaver  upon  which  lateral  lithotomy  had  been  performed 
for  the  purpose  of  determining  these  points.1 

If  the  stone  is  large  and  the  tractions  made  with  too  much 
force,  the  neck  of  the  bladder  may  be  torn  off,  but  more 
commonly  the  incision  is  lengthened  by  tearing  at  its  outer 

i    The  incision  was  made  as  if  for  the  removal  of  a  stone  one  inch  in  diameter. 
The  cadaver  was  tliut  of  a  mulatto  ahout  twenty-five  years  old. 


SPECIAL  OPERATIONS. 


527 


end,  an  accident  which  is  much  less  dangerous  than  extend- 
ing the  incision  with  the  knife  would  be,  for  it  spares  the 
rich  plexus  of  veins  about  the  prostate. 


Fjg.  2C9. 


Lateral  lithotomy.  Incision  of  the  neck  of  the  hladder  as  seen  from  within. 
A  is  a  rent  in  the  wall  made  by  the  introduction  of  the  finger.  B  is  an  extension 
of  the  incision  involving  only  the  mucous  membrane. 

Lateral  Lithotomy.  The  instruments  required  are  a  staff 
with  a  long  curve,  deeply  grooved  on  its  convexity  (Fig. 
270),  a  stout  scalpel  with  a  cutting  edge  of  one  and  one- 
half  inches  (Fig.  271),  a  Blizard's  kuife  (Fig.  272),  a  blunt 
gorget  (Fig.  273)  if  the  patient  is  fat,  a  scoop  (Fig.  274), 
forceps  of  different  patterns  (Figs.  275,  276,  277),  a  syringe 
and  tube  for  washing  out  fragments,  and  a  shirted  canula 
(Fig.  278)  to  control  hemorrhage.  The  latter  can  be  readily 
made  by  passing  the  beak  of  a  female  silver  catheter  through 
the  centre  of  a  piece  of  iodoform  gauze  eight  inches  square, 
and  tying  the  two  firmly  together,  as  shown  in  the  figure. 
It  is  then  introduced  into  the  wound,  the  beak  of  the 
catheter  in  the  bladder,  the  pouch  tightly  packed  afterward 
with  pledgets  of  gauze,  and  the  whole  kept  in  place  by  a 
T-bandage.  Three  assistants,  at  least,  are  required  :  one 
to  administer  the  anaesthetic,  the  others  to  hold  the  knees 
and  the  staff. 


528 


Fig.  270. 


OPERATIVE  SURGERY. 

Fig.  271.         Fig.  272.  Fig.  273.  Fig.  274. 


Gorget.       Scoop. 


Lithotomy  stall. 


Operation.1  The  patient,  having  had  his  bowels  emptied 
by  an  enema,  is  placed  upon  his  back,  his  ankles  bound  fast 
to  his  wrists  (Fig.  279),  the  staff  introduced,  and  the  stone 
touched  with  it.     It  is  an  absolute  rule  that  if  the  stone 


>  Van  Buren  and  Keyes :   Genito-Urinary  Diseases  and  Syphilis, 


p.  335. 


SPECIAL  OPERATIONS. 


529 


cannot  be  felt  with  the  staff  or  a  searcher  after  the  patient 
has  been  etherized  and  placed  upon  the  table,  the  operation 
must  be  postponed.  It  is  not  necessary  that  the  beak  of 
the  staff  should  rest  upon  the  stone  during  the  operation  ; 


Fig.  275. 


Figs.  276,  277. 


Fig.  278. 


Shirted  canula. 


on  the  contrary,  it  is  better  to  hook  the  staff  up  under  the 
symphysis  so  as  to  keep  it  steady,  with  its  curve  bellied 
out  in  the  median  line  of  the  perineum,  and  the  integument 
stretched  over  it  by  drawing  the  scrotum  up  around  the 
staff. 

The  operator  passes  his  index-finger  into  the  rectum,  and 
satisfies  himself  that  the  staff  enters  at  the  apex  of  the  pros- 
tate and  passes  centrally  through  it,  and  that  the  rectum  is 
empty.  Then  withdrawing  his  finger  he  feels  along  the 
raphe  of  the  perineum  for  the  groove  in  the  staff,  aiding 
himself,  if  necessary,  by  depressing  and  raising  the  handle 
several  times. 


530 


OPERA  TIVE  S URGER  Y. 


Having  found  the  groove  he  confides  the  staff  to  his  chief 
assistant,  enters  the  scalpel  a  little  to  the  patient's  left  of 
the  raphe,  from  one  and  one-quarter  to  one  and  one-half 
inches  in  front  of  the  anus,  and  passes  it  in  almost  parallel 
to  the  rectum  so  as  to  enter  the  groove  about  half  an  inch 
in  front  of  the  apex  of  the  prostate,  guiding  it,  if  he  thinks 


Fig.  279. 


Position  of  patient  and  line  of  incision  in  lateral  lithotomy. 

best,  by  keeping  his  left  index-finger  upon  the  prostate  in 
the  rectum.  (If  the  knife  should  be  passed  directly  in  to 
the  nearest  point  on  the  staff,  the  bulb  would  be  involved 
to  an  unnecessary  extent.)  As  soon  as  the  point  of  the 
knife  has  entered  the  groove,  it  is  pushed  along  for  half  an 
inch,  dividing  the  floor  of  the  urethra  to  that  extent,  and 
then  withdrawn,  cutting  steadily  downward  and  outward  so 
as  to  make  a  cutaneous  incision  about  three  inches  long, 
passing  midway  between  the  anus  and  left  tuber  ischii. 

The  probe-pointed  Blizard's  knife,  guided  upon  the  left 
index-finger,  is  passed  into  the  groove,  and  the  surgeon 
takes  the  handle  of  the  staff  from  the  assistant,  depresses  it 
somewhat,  and  pushes  the  knife  along  until  its  point  is  ar- 
rested at  the  termination  of  the  groove  at  the  end  of  the 
staff.  Then  depressing  the  handle  of  the  knife,  and  bear- 
ing in   mind  the  shape  and   position  of  the  prostate,  he 


SPECIA  L  OPER  A  TIO  NS. 


531 


makes  an  incision  in  it  downward  and  outward  at  an  angle 
of  about  30°  with  the  horizon  (Fig.  280). 

The  index-finger  is  next  introduced,  the  staff  withdrawn, 
and  the  neck  of  the  bladder  gently  dilated  with  the  finger, 
or,  if  the  perineum  is  deep  and  fat,  with  the  blunt  gorget 
carried  in  along  the  groove  in  the  staff.  If  the  stone  is 
more  than  an  inch  in  diameter,  the  Blizard  knife  must  be 
reintroduced  and  the  prostate  cut  upon  its  right  side  also. 


Fig.  280. 


Lateral  lithotomy.    Relations  of  the  two  incisions  to  each  other  and.  to  the 
prostate.    (Thompson.) 

The  forceps  are  then  introduced  as  the  finger  is  with- 
drawn, and  the  stone  sought  for  by  opening  and  closing 
the  blades  at  different  poiuts  on  the  floor  of  the  bladder  ;  or 
the  small  end  of  the  scoop  may  be  introduced,  placed  in 
contact  with  the  stone,  and  the  forceps  guided  along  it.  If 
the  stone  is  seized  in  a  faulty  direction,  it  must  be  dropped 
and  caught  again,  or  straightened  with  the  fingers  while 
still  held  between  the  blades.  Extraction  should  be  made 
slowly  downward  and  outward  in  the  line  of  the  external 


532  OPERATIVE  SURGERY. 

incision,  and  aided  by  lateral  movements  of  the  handles. 
The  old  rule  was  that  the  force  used  should  be  two-thirds 
lateral,  one  third  extractive.  If  it  is  found  that  the  stone 
is  too  large  to  be  removed  without  employing  too  much 
force,  it  must  be  crushed  and  the  fragments  removed  sep- 
arately. Small  stones  and  fragments  are  best  removed 
with  the  scoop  and  by  thorough  washing. 

In  operating  upon  children  certain  modifications  are  re- 
quired. The  prostate  being  very  small  the  incision  usually 
passes  quite  beyond  its  limits,  but  this  is  a  matter  of  slight 
importance  since  the  ill  results  which  follow  in  adults  and 
old  men  do  not  occur  at  this  age.  If  the  incision  in  the 
urethra  and  at  the  neck  of  the  bladder  is  not  sufficiently 
free,  it  may  happen  that,  in  the  attempt  to  introduce  the 
finger,  the  urethra  will  be  torn  entirely  across  and  the  blad- 
der pushed  up  before  it.  Again,  the  bladder  is  placed 
higher  in  the  child  than  it  is  in  the  adult,  aud  therefore 
the  point  of  the  knife  must  be  more  raised  in  making  the 
deep  incision,  and  care  must  be  taken  not  to  let  it  slip  in 
between  the  rectum  and  bladder.  Mr.  Erichsen1  says  he 
has  known  this  to  occur  in  several  instances,  and  the  for- 
ceps to  be  passed  into  this  space  under  the  impression  that 
it  was  the  bladder. 

It  has  also  happened  to  some  surgeons  to  force  the  beak 
of  the  staff  through  the  roof  of  the  urethra  into  the  space 
between  the  bladder  and  posterior  face  of  the  pubes,  and  to 
be  so  deceived  by  its  freedom  of  motion  in  the  loose  cellular 
tissue  of  that  region  that  they  thought  it  was  in  the  bladder, 
aud  cut  upou  it  accordingly. 

Median  Litlbotomy.  The  only  instruments  required  other 
than  those  used  in  the  lateral  operation  are  a  staff,  director, 
and  knife.  The  staff  has  a  central,  broad,  deep  groove  on 
its  convexity  (Fig.  281),  the  director  has  a  ball-point  (Fig. 
282),  and  the  knife  is  straight,  stout,  and  sharp-pointed, 
with  a  cutting  edge  upon  the  back  also  for  a  short  distance 
from  the  point  (Fig.  283). 

The  patient  having  been  bound  in  the  lithotomy  position 
and  the  staff  introduced,  the  surgeon  places  his  left  index- 

1  Science  and  Art  of  Hurgery,  vol.  ii.  \<.  682,  Phila.,  1878. 


SPEC! A  L  OPERA  TIONS. 


533 


finger  in  the  rectum  against  the  apex  of  the  prostate,  and 
plunges  the  knife  with  its  edge  upward  into  the  raphe  of 
the  perineum  half  an  inch  in  front  of  the  anus  in  such  a 
direction  that  its  point  will  enter  the  groove  of  the  staff 
just  at  the  apex  of  the  prostate.     The  knife  is  pushed  very 


Fig.  281. 


Fig.  282. 


Fig.  283. 


Staff  for  median  lithotomy. 


Ball-pointed  director.      Double-edged  scalpel. 


slightly  back  along  the  groove  so  as  certainly  to  open  the 
urethra  and  nick  the  end  of  the  prostate,  then  brought  for- 
ward, dividing  the  membranous  portion  of  the  urethra,  and 
swept  around  the  bulb  by  raising  the  handle,  making  an 
external  incision  upward  along  the  raphe  for  about  one  and 


534 


OPERATIVE  SURGERY. 


a  quarter  inches.  The  director  is  next  passed  along  the 
staff  into  the  bladder,  the  two  separated  angularly  to  make 
partial  dilatation  of  the  neck,  the  staff  withdrawn,  and  the 
dilatation  completed  with  the  finger.  The  forceps  are  then 
introduced  and  the  stone  removed  as  in  lateral  lithotomy. 


Frn.  284. 


Median  lithotomy  with  rectangular  stafl'. 

Sir  Henry  Thompson  makes  the  incision  from  without 
inward,  and  Mr.  Erichsen  uses  a  rectangular  staff  (Fig. 
284),  placing  its  augle  close  against  the  apex  of  the  prostate. 


SUPRAPUBIC   CYSTOTOMY   FOR   VESICAL   CALCULUS. 

The  patient  aud  the  skin  surface  are  prepared  in  the 
usual  way  for  an  aseptic  operation,  and  after  etherization  the 
bladder  is  irrigated  clean  with  a  warm  saturated  solution 
of  boric  acid.  The  viscus  is  then  distended  with  as  much  of 
this  solution  as  can  be  injected  from  an  irrigator  vessel  ele- 
vated not  more  than  two  feet ;  such  a  pressure  is  harmless, 
while  the  injection  of  a  fixed  amount  of  fluid  or  the  use  of 
a  hand  syringe  may  not  be,  owing  to  the  uncertainty  as  to 
the  capacity  of  the  bladder  and  the  condition  of  its  walls. 

The  catheter  is  then  withdrawn  from  the  urethra  and  a 
thin-walled  soft-rubber  bag,  which  is  better  than  the  ordi- 
nary stiff  colpeurynter,  is  placed  in  the  rectum  above  the 
sphincter  and  cautiously  distended  by  a  Davidson  syringe, 


SPECIAL  OPERATIONS.  535 

using  not  more  than  eight  or  ten  ounces  of  water.  This 
simply  presses  the  bladder  forward  and  brings  its  floor 
more  within  reach,  but  it  does  not  materially  alter  the  rela- 
tion of  the  peritoneum  to  its  anterior  wall,  and  hence  the 
use  of  the  colpeurynter  can  frequently  be  dispensed  with. 
After  filling  the  bladder  it  is  unwise  to  constrict  the  penis, 
as  is  so  often  done,  but  the  urethra  should  be  left  free  to 
relieve  any  excessive  strain  on  the  bladder  wall. 

An  incision  two  or  three  inches  long  is  then  made  in  the 
median  line  from  just  below  the  upper  border  of  the  sym- 
physis pubis  upward  in  the  median  line  and  deepened  layer 
by  layer  as  nearly  as  possible  between  the  recti,  and  the 
underlying  fascia  is  divided. 

If  more  space  is  required  the  recti  and  fascia  can  be  cut 
transversely  to  a  greater  or  less  extent  close  to  the  pubes. 
The  peritoneum  does  not  descend  below  the  urachus,  which 
cau  sometimes  be  felt  as  a  cord  attached  to  a  knot  on  the 
fundus,  and  by  carrying  the  dissection  directly  inward 
through  the  prevesical  fat  with  blunt-pointed  scissors,  aided 
by  the  finger,  and  avoiding  unnecessary  laceration  of  the 
tissues,  the  bladder  is  exposed;  after  pushing  upward  the 
fatty  and  cellular  tissue  which  carries  the  peritoneum  with 
it,  a  tenaculum  is  inserted  in  the  highest-exposed  part  of  the 
bladder  wall  and  a  knife  is  plunged  into  it  just  below  the 
tenaculum,  opening  the  bladder  longitudinally  downward 
for  about  an  inch.  Each  side  of  the  incision  is  immedi- 
ately grasped  by  catch  forceps  which  serve  to  hold  the 
opening  in  the  abdominal  wound. 

The  peritoneum  may  descend  unusually  low  in  front,  and 
this  must  be  recognized  in  the  dissection,  which  in  such  cases 
should  be  first  downward  and  inward  behind  the  pubes 
and  theu  up  over  the  anterior  surface  of  the  bladder,  push- 
ing the  unopened  peritoneum  out  of  the  way  ;  the  numer- 
ous veins  which  are  encountered  are  drawn  aside  or  ligated 
as  they  are  divided,  but  it  is  unnecessary  to  waste  time 
searching  for  bleeding  points,  as  the  hemorrhage  generally 
ceases  spontaneously  on  opening  the  bladder. 

The  interior  of  the  latter  is  then  carefully  explored  by 
sight  and  touch,  and  any  loose  stones  are  picked  up  with 
instruments,  preceded,  if  necessary,  by  crushing  ;  the  mouth 
of  a  diverticulum  containing  a  stone  may  have  to  be  gently 


536  OPERATIVE  SURGERY. 

dilated,  but  never  cut,  and  the  stone  scooped  or  irrigated 
out,  or  first  nibbled  into  fragments  by  forceps  ;  projecting 
portions  of  the  prostate  preventing  the  free  escape  of  urine 
are  excised  as  described  under  prostatectomy,  and  finally 
the  interior  of  the  bladder  is  washed  free  from  all  clots  and 
debris  with  warm  boric  solution. 

As  a  general  rule,  a  wound  in  a  comparatively  normal 
bladder  wall  should  be  closed  with  sutures,  but  if  there  is 
much  pus  or  inflammatory  change  present  it  is  better  to 
leave  the  wound  open. 

To  insert  the  sutures  a  blunt  tenaculum  is  placed  in  each 
extremity  of  the  incision  in  the  bladder,  lifting  up  and 
steadying  it.  Interrupted  sutures  of  chromicized  catgut 
are  then  inserted  by  a  fine-curved  needle  at  intervals  of  a 
quarter  of  an  inch  close  to  the  edges  of  the  wound  and 
passing  through  the  cut  surface  without  entering  the  thin 

Pig.  285. 


Muscular  coat 

Mucous  coat 
Method  of  suturing  a  wound  of  the  bladder. 

mucous  membrane;  over  and  between  these  is  placed  a 
row  of  chromicized  catgut  Lembert  sutures  extending  a 
short  distance  beyond  the  extremities  of  the  incision,  and 
after  all  the  sutures  have  been  tied  the  bladder  is  filled 
with  boric  solution  to  test  their  efficacy. 

Weak  points  are  then  reinforced  by  additional  Lembert 
sutures.  An  iodoform -gauze  packing  is  placed  in  contact 
with  this  suture  line,  and  if  considered  necessary  one  or 
more  rubber  drainage  tubes  can  be  added  ;  the  abdominal 
wound  is  then  partially  closed  with  silk  sutures,  a  couple 
of  which  are  left  untied  till  the  drainage  is  removed  several 
days  later  if  all  goes  well,  when  the  wound  can  be  closed 
tight. 


SPECIAL  OPERATIONS.  537 

An  antiseptic  dressing  is  applied  and  a  catheter  for  con- 
tinuous drainage  is  fastened  in  the  bladder  through  a  peri- 
neal puncture  as  described  under  external  urethrotomy  by 
McBurney's  gorget.  Some  surgeons  prefer  to  leave  the 
unne  to  escape  by  its  natural  path,  or  tie  a  catheter  in  the 
urethra  for  a  day  or  two. 

In  about  half  of  the  properly  selected  cases  primary 
union  of  the  bladder  may  be  expected. 

If  the  bladder  wound  must  be  left  open  its  lips  may  be 
temporarily  fastened  in  the  margins  of  the  abdominal  inci- 
sion, and  the  latter  is  partially  closed  above  and  below,  while 
a  light  iodoform-gauze  packing  is  placed  in  any  pockets 
which  may  have  become  infected  around  the  opening  in  the 
bladder.  A  rubber  drainage  tube  with  lateral  perforations 
near  its  lower  extremity  is  then  inserted  into  the  deepest 
part  of  the  bladder,  and  the  other  extremity  passing  out  of 
the  wound  is  connected  with  a  tube  which  terminates  be- 
low the  surface  of  a  1  :  60  carbolic  solution  contained  in  a 
bottle  under  the  bed. 

To  favor  the  intended  siphon  action  of  the  tube,  at  its 
exit  from  the  bladder  it  is  surrounded  by  a  tight  iodoform- 
gauze  packing,  but  still  a  large  proportion  of  the  urine  will 
inevitably  escape  into  the  dressings,  which  will  need  very 
frequent  renewal ;  no  other  drainage  is  required.  The 
tube  is  prevented  from  slipping  out  by  a  silk  suture  passed 
through  it  and  the  skin. 

Transverse  Incision.  If  the  bladder  is  very  contracted 
and  it  is  deemed  unsafe  to  use  the  rectal  bag,  so  that  the 
bladder  must  be  sought  at  a  greater  depth  than  usual,  a 
transverse  incision  dividing  both  recti  gives  easier  access  to 
it.  This  incision,  slightly  convex  downward,  is  made  close 
along  the  upper  margin  of  the  symphysis  and  extended 
about  two  inches  to  either  side  of  the  median  line.  After 
it  has  been  carried  through  the  recti  and  fascia  into  the  pre- 
vesical space  the  subsequent  operations  are  as  above  de- 
scribed. 

Langenbuch  divides  the  suspensory  ligament  of  the  penis 
and  exposes  the  lower  part  of  the  bladder  below  the  pubes 
by  an  inverted  ^-incision.  The  vertical  limb  lies  over  the 
symphysis  and  the  oblique  ones  follow  the  edges  of  the 
descending  rami  of  the  pubes. 


538  OPERATIVE  SURGERY. 


PROSTATECTOMY. 

Suprapubic.  The  rectal  bag  is  inserted  and  filled,  and 
the  bladder  is  opened  and  washed  out,  as  already  described, 
and  if  the  enlargement  is  pedunculated  it  is  simply  sur- 
rounded with  or  without  transfixion  by  a  silk  ligature,  the 
ends  of  which  are  left  long  and  brought  out  of  the  abdom- 
inal wound,  while  the  mass  is  left  to  slough  away  or  is 
immediately  excised  with  scissors. 

When  the  projection  cannot  be  ligated  it  may  be  removed 
with  the  ecraseur  or  galvano-cautery.  The  uniform  "  collar  " 
projection  of  the  prostate  is  excised  by  dividing  its  margins 
transversely  above  and  below,  and  shelling  out  each  semi- 
circular half  with  the  fingers  after  incising  the  mucous 
membrane  on  the  summit  of  the  ridge. 

Keyes  strongly  recommends  the  use  of  the  rongeur  for- 
ceps to  cut  away  the  hypertrophied  posterior  lip  of  the 
orifice.  In  no  case  should  any  portion  of  the  projecting 
valve  be  left  behind,  and  finally  the  patency  of  the  urethral 
canal  is  ascertained  by  the  passage  of  the  finger  as  far  as 
the  first  joint. 

Hemorrhage  is  controlled  by  packing  with  iodoform 
gauze  or  by  the  cautery.  At  the  close  of  the  operation  the 
extremities  of  the  abdominal  wound  are  drawn  together 
around  the  opening  in  the  bladder,  which,  if  possible,  is 
sutured  to  the  margins  of  the  wound,  while  all  spaces  which 
are  liable  to  infection  are  packed  with  iodoform  gauze,  and 
a  siphon  drain  is  placed  in  the  bladder. 

Perineal  Prostatectomy.  The  urethra  is  opened  in  the 
membranous  portion  for  about  an  inch  or  an  inch  and  a 
half  by  an  external  urethrotomy,  and  after  inserting  a 
gorget  the  finger  is  passed  to  the  bladder  by  gradual  dilata- 
tion of  the  urethra  and  the  projection  located  and  explored. 
The  finger  must  then  be  withdrawn  to  make  room  for  the 
ecraseur,  galvano-cautery,  or  one  of  Thompson's  forceps,  by 
which  the  growth  is  snared  or  torn  from  its  attachments. 

Hemorrhage  is  checked  by  irrigation  with  very  hot  or 
very  cold  water,  or  by  packing,  and  the  subsequent  treat- 
ment is  the  same  as  for  external  urethrotomy.    This  method 


SPECIAL  OPERATIONS.  539 

is  seldom  used  because  of  its  limited  applicability  and  the 
difficulty  of  manipulation. 

For  hypertrophy  of  the  lateral  lobes  of  the  prostate 
Dittel1  proposes  an  incision  from  the  coccyx  to  the  median 
line  of  the  perineum,  passing  around  one  side  of  the 
sphincter.  The  dissection  is  carried  down  to  the  prostate 
in  front  and  at  the  sides  of  the  rectum,  which  is  rendered 
prominent  by  packing,  and  a  cuneiform  section  is  removed 
from  the  enlarged  portions  of  the  gland  like  a  tumor,  with- 
out opening  the  urethra.  The  resulting  wound  is  then 
drawn  together  with  catgut  and  a  strand  of  iodoform  gauze 
inserted  for  drainage. 

Enlarged  Prostate  Treated  by  Castration.  Cases  of  hy- 
pertrophied  prostate  complicated  by  retention  and  cystitis 
have  been  successfully  treated  by  White,  of  Philadelphia, 
and  others  by  castration.  The  prostate  atrophies  within  a 
year  or  less  and  the  obstruction  to  the  escape  of  urine  thus 
disappears.  The  operation  is  simpler  and  less  dangerous 
than  prostatectomy,  and  the  results  have  been  satisfactory. 


TUMORS    OF   THE    BLADDER. 

The  bladder  is  rendered  as  aseptic  as  possible  by  wash- 
ing and  is  then  explored  by  a  suprapubic  cystotomy. 
When  malignant  disease  is  found  lying  near  the  fundus 
(which  is  its  rarest  location),  and  of  limited  extent,  a  sponge 
is  placed  iu  the  interior  of  the  bladder  to  soak  up  all  the 
urine,  and  if  the  peritoneal  cavity  must  be  opened  to  effect 
a  thorough  removal  of  the  disease,  it  is  protected  by  a 
sponge  packing  and  the  bladder  wall  divided  with  scissors, 
including  the  peritoneum,  if  necessary,  well  outside  the 
limits  of  the  growth. 

The  peritoneal  part  of  the  wound  in  the  bladder  is  then 
closed  by  Lembert  silk  sutures,  which  must  not  enter  the 
mucous  membrane,  the  protective  packing  removed,  after 
thorough  cleansing  of  the  abdominal  cavity,  and  the  peri- 
toneum above  the  bladder  drawn  together  with    catgut. 

1  Wien.rued.  Wocli.,  1890,  No.  1S-19. 


540  OPERATIVE  SURGERY. 

The  rest  of  the  bladder  wound  is  treated  as  in  simple  supra- 
pubic cystotomy. 

If  the  cancer  occupies  the  sides  or  base  of  the  bladder 
most  surgeons,  in  this  country  at  any  rate,  advise  against 
an  attempt  at  radical  removal  and  are  content  with  curet- 
ting to  ameliorate  symptoms. 

A  few  successful  cases  are  reported  in  which  the  disease 
has  been  removed  with  the  surrounding  mucous  membrane, 
but  leaving  the  muscular  coat  from  which  the  growth  is 
sometimes  found  separated  by  a  layer  of  fat. 

Helferich1  resects  the  pubes  through  a  transverse  incision 
above  the  symphysis  and  so  gains  access  to  the  anterior  sur- 
face of  the  bladder. 

Niehans2  performs  a  very  similar  operation  which  he 
calls  an  osteoplastic  resection  of  the  pubes. 

Zuckerkandl3  exposes  the  base  and  adjacent  posterior 
surface  of  the  bladder  by  a  curved  transverse  incision 
through  the  perineum  in  front  of  the  anus  and  rectum, 
which  are  turned  down  and  drawn  back.  (See  removal  of 
seminal  vesicles.) 

Bramann4  chisels  out  a  small  piece  of  the  symphysis,  in- 
cluding the  portion  connected  with  the  recti,  by  a  T-shaped 
incision,  the  horizontal  limb  lying  above  the  pubes  between 
the  cords  and  the  vertical  over  the  symphysis ;  at  the  con- 
clusion of  the  operation  the  bone  is  sutured  back  in  posi- 
tion and  the  patient  fixed  in  a  half-sitting  position  with 
the  legs  flexed. 

For  total  extirpation  of  bladder  or  its  mucous  membrane, 
see  American  Journal  of  the  Medical  Sciences,  January, 
1891,  p.  101,  and  Wien.  med.  Presse,  1889,  No.  27-28. 

Benign  growths  which  are  more  or  less  pedunculated  are 
treated  in  the  manner  described  for  suprapubic  prostat- 
ectomy and  their  bases  scraped  or  cauterized  or  touched 
with  a  ten  per  cent,  solution  of  chloride  of  zinc. 

If  the  tumor  has  a  small  enough  pedicle,  the  latter  can  be 
grasped  by  a  pair  of  forceps  close  to  the  bladder  wall,  and 
the  tumor  twisted  off  on  the  distal  side  of  the  forceps,  which 
are  held  immovable ;  but  unless  all  portions  of  the  growth 

i  Archiv  f.  Klin.  Chir.,  1888,  p.  625.  2  Centralb.  f.  Chir.,  1888,  p.  521. 

;  Wien.  med,  Presse.  188'.).  No.  21-22.  *  Centrul.b.  f.  Chir.,  189:!.  No.  17. 


S  FECI  A  L  OPERA  TTONS. 


541 


are  removed  it  is  liable  to  recur.  Benign  tumors  can  oc- 
casionally be  torn  from  their  attachment  by  forceps  intro- 
duced through  an  external  urethrotomy  wound,  but  care 
must  be  taken  not  to  force  the  bladder  wall  into  the  grasp 
of  the  instrument  by  pressure  on  the  hypogastrium.  There 
is  less  danger  of  rupturing  the  bladder  than  might  be  sup- 
posed, owing  to  the  usual  hypertrophy  of  the  muscular 
coat  underlying  the  tumor. 


REMOVAL   OF    THE    SEMINAL    VESICLES. 


Zuckerkandl' s  Incision.2 
lithotomy  position  with  a  sound  in  tne  uretnra  to  mam  its 
position  and  the  bladder  partially  filled  with  a  saturated 


*jwn*,i witiH  a  jluviowh,.      The   patient  is  placed  in  the 
lithotomy  position  with  a  sound  in  the  urethra  to  mark  its 


Fig.  286. 


m; 


Zuckerkandl's  incision  for  removal  of  the  seminal  vesicles. 
P.  Prostate.    Vd.  Vas  deferens,     i's.  Vesicula  seminalis.    M.  Rectum. 


solution  of  boric  acid.     A  slightly  curved  incision  with 
its  concavity  towards  the  anus  is  made  transversely  across 

1  See  also  Ullmann  :  Centralb.  f.  Chir.,  Feb.  22, 1890. 
-  Wien.  mcd.  Presse,  1889,  p.  856. 

24 


542  OPERATIVE  SURGERY. 

the  perineum,  having  its  centre  about  one  inch  aud  a  half 
in  front  of  the  anus.  From  each  extremity  of  this  a 
straight  diverging  incision  about  au  inch  aud  a  half  long 
passes  back  on  either  side  of  the  anus  to  end  near  the  tuber 
ischii.  After  division  of  the  skin  and  subcutaneous  tissue 
a  finger  is  placed  in  the  rectum  and  the  perineal  septum 
cut  through,  avoiding  the  anterior  rectal  wall. 

The  dissection  is  deepened  till  above  the  sphincter  ani, 
which  is  then  turned  down  with  the  rectum  while  the  bulb 
of  the  urethra  is  pushed  forward,  and  the  pubic  portion  of 
the  levator  ani  is  divided  on  each  side  of  the  prostate. 
Free  hemorrhage  may  be  expected  from  the  hemorrhoidal 
and  prostatic  plexus  of  veins,  but  it  is  easily  controlled  by 
pressure  or  clamps.  Then,  by  tearing  through  the  loose 
connective  tissue,  the  rectum  is  easily  separated  a  little 
more  fully  from  the  bladder,  the  base  of  which  can  be  made 
more  prominent  by  manipulating  the  sound,  and  the  pros- 
tate, vasa  deferentia,  and  seminal  vesicles  are  brought  into 
clear  view. 

It  only  remains  to  dissect  off  one  or  both  vesicles  and  to 
ligate  the  corresponding  vas  deferens  with  catgut. 

The  wound  is  closed  and  dressed  antiseptically  with  a 
rubber  drainage  tube  and  light  iodoform-gauze  packing  in 
its  most  dependent  angles. 

The  vas  deferens,  cord,  and  testicle  can  be  extirpated  at 
the  same  time  by  an  incision  starting  over  the  internal  ab- 
dominal ring  and  passing  down  through  the  inguinal  canal 
into  the  scrotum.  This  incision  is  deepened  layer  by  layer 
above  the  pubes,  the  peritoneum  recognized  and  pushed  up, 
and  then  by  working  with  the  fingers  from  above  and 
below  (through  Zuckerkandl's  incision)  the  vas  can  be 
separated  from  the  bladder  and  pulled  out  through  the 
opening  in  the  abdominal  wall. 


SPECIAL  OPERATIONS  543 


CHAPTER    VII. 

OPERATIONS    UPON    THE    GENITO-URINARY   ORGANS     OF 
THE    FEMALE. 

CATHETERIZATION. 

The  surgeon,  standing  on  the  right  side  of  the  patient 
and  holding  the  catheter  in  his  right  hand,  with  its  convex- 
ity lying  on  the  palmar  surface  of  the  index-finger  and  its 
beak  not  quite  reaching  to  the  end  of  the  distal  phalanx 
(Fig.  287),  separates  the  nymphse  with  the  thumb  and  mid- 
dle finger  of  his  left  hand,  introduces  his  right  index-finger 
at  the  fourchette  and  brings  it  forward,  recognizing  the 
entrance  to  the  vagina  and  its  anterior  border,  and  stopping 
when  he  feels  the  pouting  orifice  of  the  urethra.  Then 
keeping  the  pulp  of  the  finger  below  and  in  contact  with 
the  orifice  he  passes  the  catheter  in. 

Fig.  287. 


Mode  of  holding  the  catheter. 


Unless  there  is  some  reason  to  the  contrary,  this  should 
always  be  done  without  exposure  of  the  parts. 


EXTERNAL    URETHROTOMY. 


The  Buttonhole   Operation  (Emmet)  (Fig.  288).      The 
patient  is  anaesthetized  and  placed  on  the  left  side,  and  the 


544 


OPERATIVE  SURGERY. 


fourchette  retracted  with  a  small  Siras's  speculum.  A  full- 
sized  metal  sound  is  introduced  iuto  the  urethra,  then  the 
tissues  in  the  vaginal  surface  are  caught  up  with  a  tenacu- 
lum and  divided  longitudinally  midway  between  the  meatus 


and  the  neck  of  the  bladder.     The  incision  may  then  be 
extended  with  scissors.     Neither  the  neck  of  the  bladder 


Fig.  289. 


nor  the  meatus  should  be  divided.     If  the  incision  is  to  be 
kept  open,  the  urethral  mucous  membrane  must  be  drawn 


SPECIAL  OPERATIONS. 


545 


out  through  it  and  stitched  with  catgut  to  the  edge  of  the 
divided  vaginal  surface.  The  incision  may  be  conven- 
iently made  with  Emmet's  buttonhole  scissors  (Fig.  289). 


LITHOTOMY. 


Besides  the  suprapubic,  which  is  performed  in  the  man- 
ner already  described,  there  are  the  urethral  and  vesico- 
vaginal operations.  In  the  former  the  stone  is  removed 
through  the  urethra  after  the  calibre  of  this  canal  has  been 
increased  by  an  incision  along  its  anterior  (upper)  wall,  or 
on  one  or  both  sides,  incisions  which  do  not  extend  into  the 
vagina.  In  the  latter  the  stone  is  removed  through  an  in- 
cision made  in  the  vesico- vaginal  septum. 

Urethral  Lithotomy.  The  only  instruments  actually  re- 
quired are  a  director,  a  probe-pointed  knife,  and  forceps, 
but  some  surgeons  prefer  to  make  the  incision  with  a  single 
or  double  lithotome  introduced  alone  or  upon  a  director. 
Lateral  incisions  should  incline  upward  rather  than  down- 
ward ;  consequently,  if  the  double  lithotome  is  used,  its 
concavity  should  be  turned  toward  the  symphysis.  The 
extraction  of  the  stone  requires  no  additional  description. 

Vesico-vaginal  Lithotomy.  The  patient  may  be  placed 
in  the  usual  lithotomy  position,  or  upon  the  side,  or  upon 

Fig.  290. 


Sims's  speculum. 


the  face.     A  Siras's  speculum  (Fig.  290)  is  pressed  against 
the  posterior  wall  of  the  vagina,  and  a  grooved  catheter  in- 


546  OPERA  TI VE  S UBGEB  Y. 

troduced  into  the  bladder  and  confided  to  an  assistant,  who 
keeps  it  pressed  well  against  the  vesico- vaginal  septum. 

Guiding  his  knife  upon  the  groove  the  surgeon  makes  an 
autero-posterior  incision  in  the  median  liue  of  the  anterior 
wall  of  the  vagina,  about  one  inch  in  length,  and  not  in- 
volvingthe  neck  of  the  bladder,  passes  in  his  index-finger, 
and  then  the  forceps  upon  the  finger  as  a  guide. 

Emmet  places  no  sutures,  but  allows  the  wound  to  close 
spontaneously,  keeping  the  bladder  clean  by  frequent 
washings.  Guyon  closes  the  incision  immediately  with 
sutures. 

In  a  discussion  in  the  Soci6te  de  Chirurgie1  the  fact  was 
brought  out  that  lithotomy  and  lithotrity  upon  the  female 
are  more  dangerous  operations  than  they  are  usually  said  to 
be.  The  fatal  complications  are  of  two  kinds  :  peritonitis 
in  patients  who  have  previously  been  affected  by  it;  and 
pyaemia,  originating  in  inflammation  of  the  spongio  vascu- 
lar tissue  constituting  part  of  the  vesico-vaginal  septum. 
Speaking  generally,  it  may  be  said  that  lithotrity2  is  more 
dangerous  in  the  female  than  lithotomy,  that  the  supra- 
pubic operation  should  be  used  for  large  calculi,  dilatation 
of  the  urethra  for  small  ones,  and,  with  crushing,  for  large 
friable  ones  when  the  inflammation  is  not  high  and  there 
has  been  no  previous  peritonitis  ;  urethral  or  vesico-vaginal 
lithotomy  in  other  cases.  As  to  the  comparative  merits  of 
urethral  and  vesico-vaginal  lithotomy  opinions  are  divided  ; 
the  former  is  followed  occasionally  by  permanent  inconti- 
nence ;  the  latter  by  fistula ;  probably,  too,  the  latter  is 
somewhat  more  dangerous  than  the  former. 


OCCLUSION,  OR    ATRESIA    VAGINAE. 

When  the  occlusion  is  due  simply  to  an  imperforate 
hymen  it  may  be  relieved  by  successive  punctures  with  a 
small  trocar  or  aspirator,  and  when  all  the  accumulated 
menstrual  blood  has  been  thus  removed,  and  the  cavity 

1  Bull,  de  la  Society  de  Chirurgie,  1877,  pp.  182  and  400. 

-  In  this  remark  reference  is  made  to  the  old  operation  of  lithotrity.  The  few 
cases  of  litholapaxy  in  the  female  of  which  I  have  knowledge  have  been  success- 
ful. 


SPECIAL  OPERATIONS.  547 

well  washed  out  with  a  two  or  three  per  cent,  solution  of 
carbolic  acid,  the  hymen  may  be  excised,  or  a  large  punc- 
ture made,  and  kept  open  by  frequently  passing  a  sound. 
It  must  be  remembered  that  very  serious  complications, 
such  as  peritonitis  and  septic  poisoning,  may  follow  this 
simple  operation  when  there  has  been  a  large  accumulation 
of  menstrual  blood  above  the  obstruction. 

When,  on  the  other  hand,  the  occlusion  is  due  to  incom- 
plete development  of  the  vagina,  a  more  systematic  opera- 
tion is  required.  The  surgeon  first  assures  himself  by 
digital  examination  through  the  rectum  of  the  existence  of 
the  uterus,  then  places  the  patient  upon  her  back  with  her 
thighs  flexed  and  abducted,  and  introduces  a  sound  into 
the  bladder  and  confides  it  to  an  assistant.  He  next  passes 
his  left  index-finger  into  the  rectum,  makes  a  transverse  in- 
cision across  the  centre  of  the  obliteration,  and  carries  it  in 
the  direction  of  the  uterus  by  successive  short  cuts  with  the 
knife,  or  by  tearing  with  a  director  or  his  fingers,  guiding 
his  course  by  the  sound  in  the  bladder  and  the  finger  in 
the  rectum.  As  soon  as  fluctuation  can  be  felt  in  front  of 
the  uterus  he  punctures  with  a  trocar  and  enlarges  the 
puncture  with  a  probe-pointed  bistoury. 


PERINEORRAPHY. 

Dr.  Emmet1  has  shown  that  the  lesion  previously  kuown 
as  "  partial  rupture  of  the  perineum,"  and  supposed  to  be 
a  laceration  along  the  posterior  median  line  of  the  tissues 
at  the  lower  part  of  the  vagina  and  perineum,  is  actually  a 
transverse  rent  at  or  within  the  ostium  vagiuse,  which,  by 
the  dropping  aud  eversion  of  the  lower  lip  of  the  wound,  is 
made  to  present  the  appearance  of  a  longitudinal  one.  He 
has  also  recently  recognized  and  described  a  variety  of  this 
lesion  in  which  the  laceration  is  submucous,  in  which  the 
muscular  and  fascial  diaphragm,  constituted  in  part  by  the 
sphincters  and  closing  the  outlet  of  the  pelvis,  is  torn  away 
from  the  supporting  fascia?  and  muscles  which  run  upward 
to  attach  its  centre  to  the  inner  side  of  the  bony  pelvis, 

1  Principles  and  Practice  of  Gynecology,  18S4,  p.  364. 


548 


OPERATIVE  SURGERY. 


and,  having  thus  lost  its  support,  allows  the  posterior  part 
of  the  vulva  to  be  everted,  with  production  of  a  rectocele 
by  protrusion  of  the  rectum  through  the  (subcutaneous) 
gap.  To  this  latter  condition  he  gives  the  name  prolapse 
of  the  posterior  wall  of  the  vagina.  The  two  conditions,  the 
subcutaneous  and  the  complete  rents,  are  essentially  the 
same,  and  require  nearly  the  same  denudation  of  the  sur- 
face. The  aim  of  the  operator  in  either  case  is  to  lift  up 
the  depressed  and  everted  lower  lip,  unite  its  edge  to  that 
of  the  mucous  membrane  of  the  vagina  at  the  crest  of  the 
rectocele,  aud  thus  cover  iu  the  latter  and  renew  its  ante- 
rior support. 

Laceration  of  the  vulvar  orifice  in  the  posterior  median 
line  may  occur  without  coexistence  of  the  above-described 
lesion,  beginning  at  the  fourchette  and  extending  backward, 
but  such  laceration  is  unimportant  because  it  involves  only 
parts  that  lie  outside  the  real  support  of  the  viscera. 


Fig.  291. 


Fig.  292. 


Fig.  293. 


JEVfe 

mmMMi 


Fig.  291.  Curved  scissors.    Fig.  292.  Emmet's  scissors.    Fig  293.  Thomas's 
toothed  forceps.    Fig.  294.  Sponge-holder. 


A  third  form  is  the  important  one  in  which  laceration  of 
the  sphincter  ani  in  the  median  line  takes  place.     In  non- 


SPECIAL  OPERATIONS.  549 

instrumental  delivery  this  begins  as  a  longitudinal  slit  in 
the  recto-vaginal  septum  and  extends  from  within  outward 
and  forward.  When  caused  by  the  forceps  it  begins  at  the 
fourchette  and  extends  backward.  To  this  form  Dr. 
Emmet  limits  the  term  rupture  of  the  perineum. 

Accepting  this  classification,  I  shall  describe  the  oper- 
ation for,  1st,  prolapse  of  the  posterior  wall  of  the  vagina — 
two  varieties,  with  and  without  laceration  of  the  mucous 
membrane  of  the  vagina  ;  and,  2d,  rupture  of  the  perineum 
(and  the  sphincter  ani). 

Prolapse  of  the  Posterior  Wall  of  the  Vagina.  (1st 
variety,  without  surface  laceration.)  Operation.  Thighs 
flexed  on  abdomen  and  supported  under  the  arm  of  an 
assistant  on  each  side,  who  also  draw  aside  the  labia  and 
hold  the  tenacula  during  the  act  of  denudation.  The 
operator  seizes  with  a  tenaculum  the  mucous  membrance 
of  the  vagina  at  the  crest  of  the  rectocele  in  the  median 
line  at  a  point  which  can  be  drawn  down  to  the  urethral 
orifice  by  gentle  traction,  and  having  thus  drawn  it  down, 
has  it  held  in  place  by  the  assistant.  Then,  with  two 
other  tenacula,  he  hooks  up  the  lowest  caruncle,  or  vestige 
of  the  hymen,  on  each  side,  and  draws  them  upward  and 
outward  to  the  first  tenaculum.  This  movement  creates 
an  inverted,  crescentic,  transverse  fold  within  the  vagina 
just  below  the  first  tenaculum,  its  horns  shading  gradually 
into  the  sulcus  on  each  side,  and  a  shallow  longitudinal  fold 
in  the  median  line  between  the  last  two  tenacula.  The  op- 
posed surfaces  of  these  folds  constitute  the  area  to  be  de- 
nuded. 

Dropping  one  lateral  tenaculum,  he  gives  the  other  to  an 
assistant  who  draws  it  gently  outward  to  define  by  this  trac- 
tion the  limits  of  the  denudation  on  that  side,  and  then  the 
surgeon  denudes  by  catching  up  the  mucous  membrane  with 
a  hook  or  pronged  forceps  and  removing  it  with  scissors  in 
successive  strips.  The  process  is  then  repeated  on  the  oppo- 
site side.  Care  must  be  taken  not  to  denude  too  high  on 
the  posterior  wall. 

Silver  sutures  are  then  passed  to  unite  the  parts  in  the 
positions  given  them  by  the  first  approximation  of  the  three 
tenacula,  producing  the  line  of  union  indicated  in  Fig.  295. 
The  sutures  of  the  crescentic  part  should  be  of  silver  wire ; 

24* 


550 


OPERATIVE  SURGERY. 


those  of  the  central  line  may  be  of  silver,  silk,  or  catgut. 
A  final  silver  suture  should  be  passed  through  the  labium 
near  the  caruncle  on  one  side,  across  to  the  posterior  wall 
of  the  vagina,  under  its  mucous  membrane  for  nearly  an 


Fig   295. 


Diagram  showing  the  line  of  union  and  direction  of  the  sutures. 


inch  just  above  the  edge  of  the  denudation,  and  then  through 
the  other  labium  at  a  point  opposite  to  that  at  which  it 
began. 

Fig.  296. 


Appearance  at  completion  of  operation. 

In  passing  the  sutures  a  thick,  straight  sewing-needle 
armed  with  silk  should  be  used,  and  the  tissues  to  be  tra- 


SPECIAL  OPERATIONS. 


551 


versed  by  it  should  be  pressed  forward  by  the  finger  in  the 
rectum.  The  sutures  should  not  be  buried  throughout 
their  course,  but  should  cross  the  fold  midway  between  its 


Diagram  showing  area  of  denudation.    The  parts  bearing  corresponding 
figures  are  brought  into  apposition  by  the  sutures. 

Fig.  298. 


Emmet's  operation  for  diminishing  the  vaginal  outlet  by  external  sutures. 


free  edge  and  its  bottom.  The  silver  wire  is  drawn  through 
in  the  loop  of  the  silk.  The  appearance,  when  the  opera- 
tion is  completed,  is  shown  in  Fig.  296,  the  crescentic  part 
being  hidden  within  the  vagiua. 


552  OPERATIVE  SURGERY. 

2d  Variety.  Prolapse  with  Surface  Laceration.  The 
position  of  the  patient  is  the  same  as  in  the  preceding  form, 
and  the  area  of  denudation  is  determined  in  like  manner  ; 
speaking  generally,  it  must  extend  downward  to  the  line  of 
junction  between  the  skin  and  the  cicatricial  mucous  mem- 
brane. Its  shape,  when  spread  out,  is  that  of  a  trefoil 
(Fig.  297).  The  sutures  are  passed  in  order  from  below 
upward,  and  none  tightened  till  all  are  in  place.  The 
lower  ones  are  buried  throughout  their  course  ;  the  upper 
ones  are  partly  exposed  on  each  side,  as  shown  in  Fig.  298. 
The  suture  marked  D  includes  about  an  inch  of  the  recto- 
vaginal septum  ;  the  uppermost  suture,  C,  passes  through 
the  mucous  membrane  of  the  septum  above  the  denudation, 
and  when  tightened  draws  it  down  like  a  hood  to  protect 
the  approximated  edges,  and  also  sustains  all  the  traction 
while  the  opposed  denuded  surfaces  are  uniting. 

Dr.  Emmet  leaves  the  sutures  in  place  for  about  three 
weeks. 

PEEINEOEBAPHY. 

Method  of  Hegar  or  Simon-Hegar.  Incomplete  Rupture. 
This  is  based  on  the  principle  that  the  rent  when  spread 
out  has  the  form  of  a  triangle  with  its  apex  in  the  posterior 
vaginal  wall.  (Fig.  299.)  After  every  antiseptic  precau- 
tion, bullet  forceps  are  hooked  in  the  three  following  points  : 
in  the  crest  of  the  rectocele,  in  the  posterior  vaginal  wall, 
and  in  the  opposite  lowest  caruncles,  which  lie  on  the  inner 
surface  of  each  labium  majus.  The  labia  are  held  apart  and 
traction  is  made  on  the  forceps,  thus  putting  the  tissues  be- 
tween them  on  the  stretch,  while  a  narrow  strip  of  mucous 
membrane  is  removed  on  the  lines  made  straight  by  traction, 
which  join  the  crest  of  the  rectocele  with  the  two  caruncles 
in  the  grasp  of  the  forceps.  The  space  between  these  limits 
is  rapidly  denuded,  and  the  denudation  is  continued  on  the 
posterior  vaginal  wall  and  adjacent  skin  as  far  as  the 
cicatricial  tissue  extends,  so  that  the  raw  surface  when 
flattened  out  has  the  form  of  a  triangle  with  its  apex  in 
the  rectocele,  and  its  base,  which  is  slightly  convex  toward 
the  anus,  between  the  two  lower  forceps  on  the  inner  sur- 
faces of  the  labia  majora. 


SPECIAL  OPERATIONS. 


553 


Starting  at  the  apex  (Fig.  299),  at  intervals  of  about 
three-eighths  of  an  inch,  sutures  of  silver  wire  or  silk- 
worm-gut are  passed  on  a  well-curved  needle,  so  as  to  be 
just  buried  under  the  denuded  surface,  emerging  about  a 
quarter  of  an  inch  from  its  edge. 


Fig.  299. 


ggF"        ^% 

Incomplete  rupture  of  the  perineum.    Perineorraphy  by  Simon's  method. 
(Pozzi.) 

At  least  two  of  these  sutures  should  pass  deeply  enough 
in  the  upper  lateral  portions  of  the  raw  area  to  grasp  some 
of  the  fibres  of  the  levator  ani  muscle. 

Martin's  continuous  circular  suture  applied  in  tiers  is 
considered  better  by  many  surgeons  than  the  interrupted 
suture.  Catgut  is  used,  threaded  on  a  sharply  curved 
needle. 


Laceration  of  the  Perineum,  including  the  Sphincter  Ani. 
If  the  anterior  wall  of  the  rectum  is  ruptured  for  more 


554 


OPERA TIVE  SURGER  Y. 


than  one  or  one  and  a  half  inches  above  the  upper  margin 
of  the  sphincter,  Dr.  Thomas  prefers  to  close  it  by  a  pre- 
liminary operation,  leaving  the  restoration  of  the  perineum 
for  a  subsequent  one.  Dr.  T.  Addis  Emmet  was  the  first 
to  show  why  it  is  not  sufficient  simply  to  close  the  gap  be- 
tween the  vagina  and  rectum,  and  to  demonstrate  the  need 
of  bringing  the  ends  of  the  severed  sphincter  into  close  con- 
tact with  each  other,  and  with  the  end  of  the  recto-vaginal 
septum. 

Let  Fig.  300  represent  the  perfect  sphincter,  and  Fig. 
301  the  sphincter  ruptured  and  spread  out  with  the  points 


Fro.  800. 


of  entrance  and  exit  of  needle  A  A,  the  dotted  line  showing 
the  course  of  the  suture,  including  the  end  of  the  recto- 
vaginal wall  C.  As  the  suture  is  twisted,  the  three  points 
are  brought  nearer  together,  as  in  Fig.  302,  until  they 
finally  unite,  as  in  Fig.  303.  If  the  first  needle  is  passed 
in  and  out  at  BB,  complete  union  of  the  ends  of  the  muscle 
will  not  be  obtained,  and  loss  of  function  will  persist.    The 


SPECIAL   OPERATIONS. 


555 


first  suture  is  the  important  one,  and  must  briug  the  toru 
ends  of  the  muscle  into  contact  with  each  other  and  with  the 
end  of  the  septum. 

In  freshening  the  parts  before  passing  the  needles  the 
two  lateral  triangles,  forming  the  ruptured  surface  of  the 
body  of  the  perineum,  are  denuded,  and  the  line  of  denuda- 
tion is  prolonged  backward  along  the  edge  of  the  recto- 
vaginal septum.  This  denudation  must  extend  along  the 
edge  of  the  mucous  membrane  of  the  rectum,  but  not  include 
it.     Fig.  304  is  a  schematic  representation  of  the  end  of  the 


Fig.  304. 


Fig.  305. 


Ruptured  sphincter.    First  suture. 


Complete  perineal  rupture.    First  and 
second  sutures  in  place. 


ruptured  bowel,  the  poiuts  of  entrauce  and  emergence  of 
the  needle,  and  the  course  of  the  first  suture. 

The  rule  for  passing  the  first  suture,  then,  is  to  euter  the 
needle  as  low  down  as  the  lower  edge  of  the  anus,  pass  it 


556 


OPERATIVE  SURGERY. 


thence  upward  through  the  recto- vaginal  septum,  completely 
encircling  the  rent,  and  bring  it  out  alongside  the  lower  edge 
of  the  anus  on  the  other  side.  Its  action,  then,  is  like  that 
of  a  purse  string,  it  puckers  up  the  open  parts,  controls  the 
action  of  the  sphincter,  and  guards  against  the  two  principal 
sources  of  failure,  recto-vaginal  fistula  and  non-union  of 
the  sphincter  (Fig.  305). 


Flu.  306. 


e^SSSSSSSSS 


^^^gsssss^ssss 


Half-section  through  the  pubes. 


Dr.  Emmet  now  recommends  that  this  injury  should  be 
treated  as  if  it  were  "a  recto-vaginal  fistula  in  the  median 
line,  with  the  sides  easily  approximated." 

The  denudation  is  done  with  scissors,  beginning  at  the 
outlet  and  near  the  rectal  surface,  and  continuing  from  below 
upward,  so  as  to  avoid  the  flow  of  blood  over  the  surface 
yet  to  be  freshened.  Since  the  sides  of  the  tear,  after  re- 
traction, are  not  sufficiently  broad  to  give  a  good  surface  for 
union,  a  portion  of  the  adjoining  vaginal  mucous  membrane 


SPECIAL  OPERATIONS. 


557 


must  be  removed,  and  the  angle  must  also  be  extended  on 
the  vaginal  surface  for  half  an  inch  or  more  beyoud  the 
rectal  edge.  Then,  beginning  at  the  angle,  several  trans- 
verse, interrupted  silver  sutures  are  passed  from  the  vaginal 
edge  on  one  side,  under  the  denuded  surface,  across  the  gap, 
and  under  the  opposite  denuded  surface  to  the  opposite 
vaginal  edge,  and  two  or  three  additioual  sutures  are  passed 


Fig.  307. 


Complete  laceration  of  the  perineum.   Perineorraphy— Simon-Hegar  method  : 
general  disposition  of  the  sutures.    (Pozzi.) 


by  the  old  method,  that  is,  beginning  in  the  skin  near  the 
lower  edge  of  the  anus,  continuing  up  through  the  tissues 
alongside  the  rent,  through  the  septum,  and  down  on  the 
other  side,  so  as  completely  to  include  the  rent.  Fig.  306 
shows  these  different  sutures.  The  last  two  mentioned  are 
the  2d  and  4th  in  the  figure,  counting  from  below  upward. 


558 


OPERATIVE  SUJRGEBY. 


Complete  Laceration  icith  Rupture  of  the  Sphincter  Ani. 
A  slight  modification  of  Hegar's  method  is  used  in  the 
gynecological  service  of  Roosevelt  Hospital,  and  it  gives 
most  excellent  results.  Before  denuding  the  perineum  the 
rectum  is  first  sutured.  The  edges  of  the  rent  in  the  rectum 
are  freshened  and  the  raw  surface  is  made  a  little  broader 
below  than  above  to  thoroughly  expose  the  extremities  of 

Fig.  308. 


A  B 

Complete  laceration  of  the  perineum,    l'erineorraphy— Martin's  method. 
A.  Deep  plan  of  continuous  suture. 
D.  Passage  from  the  deep  to  the  superficial.     (Pozzi.) 

the  sphincter  muscle.  The  denuded  areas  of  muscular  and 
mucous  tissue  are  then  brought  into  apposition  by  inter- 
rupted sutures  of  chromicized  catgut  or  silkworm-gut  passed 
just  within  the  limits  of  denudation  at  intervals  of  about  a 
quarter  of  an  inch  and  knotted  in  the  rectum  from  above 
downward  (Fig.  307).  The  ends  are  left  long  and  protrud- 
ing from  the  anus,  and  at  the  expiration  of  a  couple  of  weeks 


SPECTAL  OPERATIONS.  559 

those  sutures  which  can  be  reached  are  removed  and  the 
ends  of  the  others  are  cut  short  and  the  sutures  are  left  to 
cut  their  way  out. 

The  rest  of  the  operation  is  then  finished  by  Hegar's 
method  for  incomplete  rupture  with  Martin's  continuous 
sutures  of  catgut  placed  in  tiers  from  the  bottom  of  the 
rent  just  external  to  the  rectal  wall  up  to  the  original  level 
of  the  vaginal  mucous  membrane  (Fig.  308).  A  tension 
suture  of  silk  should  be  passed  through  the  skin  of  the 
perineum,  without  entering  the  rectum,  a  little  beyond  the 
extremities  of  the  freshly  united  sphincter  and  the  ends  of 
the  suture  fastened  over  lead  buttons  or  balls,  which  will 
permit  it  to  be  loosened  if  there  is  much  subsequent  swell- 
ing or  oedema. 

VESICOVAGINAL   FISTULA. 

The  patient  is  prepared  for  the  operation  by  measures 
directed  to  the  improvement  of  her  general  condition,  by 
regularly  syringing  the  vagina  with  warm  water,  and  by 
dividing  any  cicatricial  bands  that  may  have  formed  in  it. 

Position.  Dr.  Thomas  recommends  the  position  known 
as  Sims's.  The  patient  is  placed  upon  the  left  side,  with 
the  thighs  flexed,  the  right  rather  more  so  than  the  left,  the 
left  arm  is  drawn  behind  her  back,  and  her  chest  brought 
flat  down  upon  the  table.  Others  prefer  the  knee-elbow 
position,  and  Simon  placed  the  patient  flat  upon  her  back, 
raised  the  hips,  and  flexed  the  thighs  as  far  as  possible  upon 
the  abdomen. 

Fig.  309. 
a 

b 

o '  e 

a.  Vesical  surface.    6.  Vaginal  surface,    cc.  Line  of  paring. 

If  the  first  position  is  employed,  an  assistant  stands  be- 
hind the  patient,  draws  the  posterior  wall  of  the  vagina  back 
by  means  of  a  broad  Sims's  speculum  held  in  his  right  hand, 
while  with  his  left  he  raises  the  right  side  of  the  nates. 


560 


OPERATIVE  SURGERY. 


The  surgeon  then  pinches  up,  with  toothed  forceps  or  a 
tenaculum,  the  vaginal  edge  of  the  fistula  at  the  point  most 
difficult  of  access,  and  cuts  off  a  piece  including  in  breadth 


Fig.  310. 


Drawing  down  the  uterus  to  facilitate  the  paring. 


all  between  the  vesical  edge  of  the  fistula  and  a  point  in  the 
vagina  at  least  one-third  of  an  inch  from  the  vaginal  edge 
of  the  fistula.    The  cutting  may  be  done  with  curved  scissors 


SPECIAL  OPERATIONS. 


561 


or  a  narrow-Waded  knife.  Successive  portions  of  the  edge 
are  raised  and  removed  in  like  manner,  until  the  denudation 
is  complete,  the  resulting  raw  surface  being  funnel-shaped, 
with  its  narrowest  part  at  the  edge  of  the  vesical  mucous 


a   Vesical  surface,    b.  Vaginal  surface,    c.  Needle. 


Fig.  313. 


as 


Needle-holder. 


Passing  the  needle. 


membrane,  the  membrane  itself  not  being  included  in  it 
(Fig.  309).  Or  the  point  of  the  knife  may  be  entered  into 
the  mucous  membrane  of  the  vagina  one-third  of  an  inch 
from  the  edge  of  the  fistula,  brought  out  at  the  vesical 


562 


OPERATIVE  SURGERY. 


border,  and  then  carried  right  and  left  around  the  opening 
so  as  to  cut  off  a  complete  ring  of  tissue. 

If  the  anterior  wall  of  the  vagina  is  freely  movable, 
Simon  brings  the  fistula  into  plain  view  by  passing  a  stout 
ligature  through  the  cervix  of  the  uterus  and  drawing  it 
down  toward  the  vulva  (Fig.  310).  He  also  pares  the 
edges  of  the  fistula  very  freely,  and  does  not  hesitate  to 
include  the  mucous  membraue  of  the  bladder  in  the  incision. 


Fig.  314,  315,  316. 


Fig.  317. 


As  soon  as  the  hemorrhage  has  ceased,  the  sutures  may 
be  passed.  The  needle,  three-quarters  of  an  inch  long, 
round,  slightly  curved,  and  armed  with  a  fine  double  silk 
suture,  is  fixed  in  a  needle-holder  (Fig.  311),  and  entered 
at  the  angle  of  the  wound  which  is  most  difficult  of  access, 
half  an  inch  from  theedgeof  the  raw  surface,  and  its  point 
brought  out  at  the  edge  of  the  vesical  mucous  membrane, 
but  not  including  it  (Fig.  312),  and  there  fixed  with  a  blunt 


SPECIAL  OPERATIONS. 


563 


hook  (Fig.  316),  until  it  can  be  seized  and  drawn  through 
with  the  needle  forceps.  It  is  then  entered  at  the  corre- 
sponding point  on  the  opposite  side,  and  brought  out  on  the 


Fig.  318. 


Simon's  method  of  placing  the  sutures. 


vaginal  surface  half  an  inch  from  the  edge  of  the  opening 
(Fig.  313).  The  ends  of  the  ligature  are  given  into  the 
charge  of  the  assistant  who  holds  the  speculum,  and  another 


564  OPERATIVE  SURGERY. 

needle  is  passed  in  the  same  manner  at  the  distance  of  one- 
sixth  of  an  inch  from  the  first  :  and  so  on,  nutil  a  sufficient 
number  have  been  passed.  During  the  passing  of  the 
needles  the  sides  of  the  fistula  are  fixed  by  the  tenaculum. 

When  the  needle  is  seized  with  forceps  and  pulled 
through,  counter-pressure  must  be  made  upou  the  tissues, 
and  this  is  best  done  by  means  of  the  split  rod  or  fork, 
represented  in  Fig.  315,  its  prongs  passing  on  either  side 
of  the  needle. 

After  all  the  ligatures  have  been  passed,  a  silver  wire, 
about  twelve  inches  long,  is  fastened  to  the  loop  of  the  first 
ligature  (Fig.  317,  C),  and  drawn  through  with  the  help  of 
the  fork.  The  silk  is  cut  oif,  the  ends  of  the  wire  drawn 
aside  out  of  the  way,  and  the  others  passed  in  the  same 
manner. 

Simon  used  fine  silk  sutures  (two  rows  when  the  fistula 
was  large)  tied  in  the  ordinary  manner,  and  often  passing 
through  the  vesical  mucous  membrane  (Fig.  318). 

The  ends  of  the  silver  sutures  being  drawn  together,  and 
the  edges  of  the  wound  carefully  approximated,  each  thread 
is  slightly  twisted  so  as  to  keep  the  parts  in  apposition,  and 
then  the  ends  of  the  first  are  seized  with  forceps  and  twisted 
with  the  help  of  the  shield  (Fig.  314),  as  shown  in  Fig. 
317  ;  care  being  taken  not  to  twist  so  tightly  as  to  stran- 
gulate the  tissues  engaged  in  the  loop.  The  other  sutures 
are  then  twisted  in  the  same  manner,  and  the  euds  of  each 
cut  off  about  half  an  inch  from  the  surface  (Fig.  319). 

Fig.  319. 


The  bladder  is  then  syringed  to  remove  any  blood  that 
may  have  collected  in  it,  and  a  Situs's  catheter  (Fig.  320) 
passed  into  it  and  left  there. 

The  sutures  may  be  removed  during  the  second  week. 


SPECIAL  OPERATIONS.  565 

Creation  of  a  Vesico-vaginal  Fistula.  This  operation 
is  sometimes  required  in  the  treatment  of  chronic  cystitis. 
Dr.  Emmet1  performs  it  as  follows :  Ansesthesia ;  Sims's 
position.  A  Sims's  speculum  is  introduced  into  the  vagina, 
and  a  director,  abruptly  curved  an  inch  and  a  half  from  its 
extremity,  introduced  through  the  urethra.  While  the 
director  is  held  by  an  assistant  with  its  point  firmly  press- 
ing in  the  median  line  against  the  base  of  the  bladder  a 


Fig.  320. 


Sims's  catheter. 

little  behind  the  neck,  the  surgeon  seizes  the  projecting 
tissue  on  the  vaginal  surface  with  a  tenaculum,  and  ex- 
poses the  beak  of  the  director  by  cutting  upon  it  with  a 
pair  of  scissors.  One  of  the  blades  of  the  scissors  is  then 
passed  through  the  opening  and  a  cut  made  backward  in 
the  median  line. 

If  the  opening  tends  to  close  spontaneously  too  soon,  a 
hollow  glass  stud  made  of  half-inch  tubing  should  be  but- 
toned into  it.  The  vesical  rim  of  this  stud  need  not 
be  more  than  a  slight  flare,  the  vaginal  rim  should  be 
larger. 


OBLITERATION   OF   THE   VAGINA  ;   KOLPOKLEISIS. 

(Fig.  321.)  When  a  vesico-vaginal  fistula  cannot  be 
closed  by  the  means  above  described,  the  escape  of  urine 
may  be  prevented  by  closing  the  vagina.  Vidal  de  Cassis 
first  performed  this  in  1833  by  effecting  union  between  the 
labia  majora,  but  it  has  been  found  that  complete  closure 
canuot  be  thus  obtained,  a  small  opening  remaining  at  the 
lower  angle.     Simon's  method  of  uniting  the  anterior  and 


1  Chronic  Cystitis  in  the  Female,  American  Practitioner,  February,  1872,  and 
Vesico-vaginal  Fistula,  p.  43. 

25 


566 


OPERA  TIVE  S  URGER  Y. 


posterior  walls  of  the  vagina  instead  of  the  labia  is  much 
more  trustworthy.     It  was  first  performed  in  1855. 

Fig.  321. 

iWiiiBW^ 


Obliteration  of  the  vagina. 


A  strip  of  mucous  membrane  encircling  the  vagina  just 
below  the  fistula  is  removed,  the  opposing  raw  surfaces 
brought  together  by  sutures,  and  the  bladder  kept  empty 
by  a  catheter  until  union  has  taken  place. 


SPECIAL  OPERATIONS. 


567 


ELYTRORRAPHY,    OR    NARROWING    OF    THE    VAGINA. 

This  is  an  operation  intended  to  prevent  prolapse  of  the 
uterus.  The  method,  introduced  by  Sims,  of  removing  a 
lougitudinal  strip  of  mucous  membrane  from  each  side  of 
the  vagina,  and  bringing  the  raw  surfaces  together,  has 


Fig.  3 


Emmet's  operation  for  procidentia. 


proved  not  ouly  inefficient,  but  often  actually  harmful  by 
supplying  a  pouch  in  which  the  cervix  became  engaged, 
thus  causing  extreme  retroversion.  Dr.  Emmet  avoided 
this  defect  by  closing  the  pouch  at  its  upper  end,  but  the 
mechanical  difficulties  in  the  way  of  performing  the  opera- 


568  OPERATIVE  SURGERY. 

tion  are  so  great  that  he  has  substituted  for  it  another  in 
which  he  catches  up  ou  a  tenaculum  three  folds  of  the 
vaginal  mucous  membrane,  one  on  each  side,  and  the  third 
in  front  of  the  cervix  (Fig.  322),  denudes  them  over  a  space 
half  an  inch  square,  and  draws  them  together  with  a  suture. 
The  three  folds  radiating  from  these  points  are  then  pared, 
and  united  stitch  by  stitch  along  the  anterior  wall  of  the 
vagina. 

Dr.  Thomas  suggests1  a  method  which,  he  thinks,  prom- 
ises well.  It  may  be  performed  upon  either  vaginal  wall, 
or  on  both  in  two  successive  operations.  While  doing  it, 
the  uterus  may  be  left  in  complete  prolapse,  or  it  may  be 
previously  returned  to  the  pelvis. 

Suppose  an  operation  on  the  anterior  wall,  the  uterus 
prolapsed.  Dorsal  decubitus.  The  mucous  membrane  of 
the  vagina  half  an  inch  from  one  side  of  the  cervix  is 
pinched  up,  and  a  small  hole  made  in  it  through  which  a 
grooved  director  is  passed  directly  across  the  anterior  face 
of  the  uterus,  between  it  and  the  vagina,  to  the  correspond- 
ing point  on  the  other  side  of  the  cervix.  Upon  this  di- 
rector the  vagina  is  cut  transversely.  The  director  is  again 
entered  at  the  centre  of  the  transverse  incision,  worked  up 
through  the  loose  areolar  tissue  between  the  bladder  and 
vagina  nearly  to  the  meatus,  and  then  withdrawn.  A  steel 
instrument  (Fig.  323),  as  large  as  a  No.  9  sound,  with 
blades  three  inches  long,  is  passed  along  the  channel  made 

Fig.  323. 


G.T  I  EM A  UN-CD. 

Thomas's  dilating  forceps. 

by  the  director  and  opened  forcibly  so  as  to  tear  the  sub- 
cutaneous tissue  and  separate  the  bladder  from  the  vagina 
over  a  triangular  space,  the  apex  of  which  is  near  the  meatus 
and  the  base  at  the  cervix. 

The  ends  of  the  transverse  incision  are  then  brought 
together  by  a  suture,  the  result  being  that  the  loosened 

1  Discuses  of  Women,  4th  edition,  p.  3")4. 


SPECIAL  OPERATIONS. 


569 


triangular  portion  of  mucous  membrane  hangs  down  and 
forms  a  longitudinal  fold  ;  this  fold  is  engaged  between  the 
blades  of  a  toothed  clamp  three  inches  long  and  half  an  inch 


Fig.  324. 


wide  (Fig.  324),  placed  with  its  hinge  at  the  cervix  and 
tightened  by  means  of  the  screw.     Then  the  portion  of  the 


Fig.  325 


Colpo-periueorraphy  by  Hegar's  method.     (Pozzi.) 


vaginal  mucous  membrane  hanging  out  of  the  clamp  is  cut 
off,  the  edges  of  the  wound  brought  together  with  interrupted 
silver  sutures,  and  the  uterus  returned  with  the  clamp  still 


570 


OPERA  TIVE  S  UR  GER  Y. 


in  place.  The  vagina  is  then  firmly  plugged  with  cotton 
wet  with  a  solution  of  alum  and  carbolic  acid,  to  prevent 
hemorrhage;  this  plug  should  be  removed  at  the  end  of 
twenty-four  hours,  the  clamp  after  forty-eight  hours,  and 
the  sutures  in  eight  or  nine  days. 


Fig.  326. 


Colpo-perineorraphy  by  Martin's  method.     Bilateral  denudation  of  posterior 
vaginal  wall ;  continuous  sutures  in  layers.    (Pozzi.) 

For  the  operation  upon  the  posterior  wall  of  the  vagina, 
or  when  the  uterus  is  in  place,  the  transverse  incision  at  the 
cervix  should  not  be  made,  the  dilating  forceps  being  passed 
in  the  opposite  direction. 

Posterior  Elytrorraphy  or  Oolporraphy.  (Hegar's 
Method.)  The  entire  thickness  of  a  portion  of  the  mucous 
membrane  is  removed  from  the  posterior  vaginal  wall  in  the 
form  of  an  isosceles  triangle  (Fig.  325),  with  its  base  about 
two  inches  broad  at  the  fourchette,  and  its  apex  in  the 
median  line  two  inches  above  the  fourchette.  For  very 
marked  prolapse  these   measurements  may  be  extended  a 


SPECIAL  OPERATIONS.  571 

quarter  or  half  an  inch.  The  denuded  area  is  folded 
together  by  the  interrupted,  or  better  by  Martin's  suture  as 
described  for  perineorraphy. 

Martin's  Method  (Fig.  326).  Two  narrow  strips  ot 
mucous  membrane  are  removed  from  the  posterior  vaginal 
wall  on  each  side  of  the  median  line  from  just  below  the 
cul-de-sac  to  a  finger's  breadth  above  the  fourchette. 

The  operation  is  completed  by  perineorraphy  with  Mar- 
tin's suture  throughout. 

Anterior.  A  portion  of  the  entire  thickness  of  the  mu- 
cous membrane  on  the  anterior  vaginal  wall  is  excised  in 
the  form  of  a  circle,  oval  or  diamond,  measuring  generally 
about  an  inch  or  an  inch  and  a  half  in  its  longitudinal 
diameter,  and  situated  about  the  same  distance  from  the 
meatus. 

The  denuded  surface  is  folded  together  by  the  interrupted 
or  purse  string  or  Martin's  suture. 


LACERATED    CERVIX. 

Dr.  Thomas  Addis  Emmet1  was  the  first  to  point  out  that 
after  laceration  of  the  cervix  the  lips  rolled  out,  their  mu- 
cous membrane  became  eroded  by  contact  with  the  floor  of 
the  pelvis,  and  that  the  proper  method  of  treatment  was  to 
freshen  the  torn  surfaces  and  bring;  them  together  with 
sutures,  so  as  to  restore  to  the  cervix  its  normal  size  and 
form.  In  cases  which  have  long  remained  unrecognized  or 
untreated,  the  lips  become  centrally  enlarged  by  the  inflam- 
matory process,  so  that  they  canuot  be  properly  brought 
together  until  after  the  removal  of  a  thick  piece  on  each 
side  of  the  inside  of  each  lip  (Figs.  327  and  328).  In 
like  manner,  when  the  eversion  is  increased  and  the  coapta- 
tion of  the  lips  prevented  by  cystic  degeneration  of  the 
mucous  follicles  lining  the  cervical  canal,  and  by  vascular 
engorgement  due  to  the  inflammation  and  to  a  constriction 
by  the  everted  edge  of  the  cervix,  similar  to  that  observed 
in   paraphimosis,  free   punctures   must  be   made  with  the 

1  American  Journal  of  Obstetrics,  November,  1874. 


572 


OPERA TIVE  SUBGER Y, 


point  of  a  knife  to  let  out  the  blood  aud  the  contents  of  the 
cysts.  It  is  well  to  do  this  several  days  or  weeks  before  the 
operation,  apply  tincture  of  iodine  to  the  cervix,  and  bring 
the  lips  together  temporarily  by  putting  a  plug  of  cotton 
into  the  posterior  cul-de-sac  and  leaving  it  there  for  several 
hours  at  a  time.  The  puncturing  and  application  of  iodine 
must  be  frequently  repeated  until  the  cysts  shall  have  all 
disappeared  and  the  erosions  become  nearly  or  entirely  healed. 
The  patient  is  placed  on  her  left  side,  a  Sims's  speculum 
introduced,  aud  a  loop  of  wire  placed  around  the  cervix 
above  the  vaginal  reflection  and  tightened  by  drawing  its 


Fig.  327. 


Fig.  328. 


Lacerated  cervix.    Side       Lacerated  cervix.    Showing  denuded  surface  (the 
view.  shaded  part)  and  sutures. 


ends  down  through  a  canula  so  as  to  prevent  bleeding  ;  or 
an  injection  of  hot  water  just  before  the  operation  will 
answer  the  same  purpose.  The  lips  are  then  separated  and 
the  lacerated  surfaces  thoroughly  freshened  with  curved  or 
angular  scissors  or  a  knife,  leaving  a  broad  uudenuded  strip 
in  the  centre  to  form  the  lining  of  the  restored  canal.  This 
strip  should  be  shaped  somewhat  like  an  hour-glass  in  order 
to  allow  for  the  shrinking  of  the  cervix  which  follows  the 
operation  (Fig.  328).  The  freshening  should  be  done  from 
below  upward,  so  that  the  blood  may  not  interfere,  and  must 
be  carried  deeply  enough  to  remove  all  diseased  glands  and 
follicles. 

A  tenaculum   is  then  engaged  in  each   lip,  and  the  two 


SPECIAL  OPERATIONS.  573 

drawn  together ;  if  proper  coaptation  is  prevented  by  the 
central  enlargement  of  the  cervix  above  mentioned,  simple 
freshening  of  the  surface  is  not  sufficient,  but  a  greater 
thickness  of  tissue  must  be  removed.  The  freshening  at 
the  angles  of  the  fissure  should  be  superficial,  so  as  not  to 
involve  the  circular  artery  which  often  lies  just  at  that  point. 
The  sutures  should  be  of  silver  wire,  and  passed  with  a 
short,  round  needle  if  the  tissues  are  soft,  or  with  a  lance- 
shaped  one  if  they  are  dense  and  indurated.  From  three 
to  five  will  be  needed  on  each  side  if  the  laceration  is  ex- 
tensive and  double.  The  first  one  on  each  side  should  be 
entered  just  beyond  the  angle  of  the  fissure  so  as  to  include 
the  branches  of  the  circular  artery  if  necessary.  The  needle 
is  entered  on  the  outside  of  the  lip  and  brought  out  at  the 
edge  of  the  undenuded  strip  which  is  to  form  the  canal,  and 
then  passed  in  the  opposite  direction  (from  within  outward) 
at  corresponding  points  through  the  other  lip.  Care  must 
be  taken  to  obtain  accurate  approximation  along  the  vaginal 
edge,  but  the  inner  edges  of  the  denuded  surfaces  do  not 
require  attention. 


POSTERIOR   SECTION    OF   THE    CERVIX. 

This  operation  may  be  rendered  necessary  by  irreducible 
flexion  of  the  uterus.     The  patient  being  placed  in  position 

Fir.  329. 


Sims's  knife. 


and  a  Sims's  speculum  introduced,  the  cervix  is  fixed  by  a 
tenaculum  and  its  posterior  lip  divided  with  scissors  as  high 
as  to  the  vaginal  junction.  The  blade  of  a  Sims's  knife 
(Fig.  329)  is  then  introduced  through  the  os  internum,  and 
the  tissues  cut  so  as  to  lay  open  the  posterior  wall  of  the 

25* 


574 


OPERA  TIVE  S  UB GEB  Y. 


cervix  (Fig.  330).  The  blade  is  theu  turned  toward  the 
anterior  wall,  and  the  little  shoulder  which,  as  Dr.  Emmet 
has  pointed  out,  usually  exists  there  at  the  poiut  of  flexion 
is  cut  through.  Instead  of  making  this  second  incision  Dr. 
Wylie  practises  and  recommeuds  divulsion  with  a  strong 
steel  dilator. 

Fig.  330. 


Posterior  section  of  the  cervix. 


A  roll  of  cotton  saturated  with  a  solution  of  persulphate 
of  iron,  one  part  to  two  of  water,  is  placed  so  as  to  occupy 
the  whole  cervix,  and  retained  by  a  plug  of  wet  cotton  in 
the  vagina. 


OPERATIONS    ON    THE    UTERUS    AND    ADNEXA. 


Anatomy.  The  broad  ligaments,  consisting  of  two  layers 
of  peritoneum,  continuous  with  that  which  covers  the  uterus, 
are  attached  to  its  sides  from  the  cornua  to  the  level  of  the 
internal  os ;  externally  they  arc  attached  to  the  sides  of  the 
pelvis  in  a  vertical  but  broader  line,  about  midway  between 
the  obturator  foramen  and  the  great  sciatic  notch.  The 
Fallopian  tube  passes  outward  from  the  angle  of  the  uterus 
in  the  highest  part  of  the  broad  ligament,  while  in  front 


SPECIAL  OPERATIONS.  575 

and  a  little  lower  down  the  round  ligament  diverges  to  the 
internal  abdominal  ring,  and  contains  a  branch  of  the  epi- 
gastric artery  passing  to  the  uterus.  Behind  the  Fallopian 
tubes  are  the  ovaries  which  are  subject  to  great  variation 
in  position — normally  each  occupies  the  apex  of  a  liga- 
mentous triangle  directed  backward,  the  base  of  which  is 
in  the  broad  ligament,  and  through  which  the  branches  of 
the  ovarian  artery  and  the  pampiniform  plexus  of  veins 
enter  the  gland.  The  inner  angle  of  the  ligamentous 
triangle  passing  to  the  fundus  of  the  uterus  is  a  rounded 
fold  of  peritoneum  containing  muscular  fibre,  and  called 
the  utero-ovarian  ligament.  The  outer  angle  blends  with 
the  upper  border  of  the  broad  ligament,  aud  is  called  the 
infundibulo-pelvic  ligament. 

The  ovarian  arteries  arise  from  the  abdominal  aorta,  and 
at  the  brim  of  the  pelvis  cross  the  bifurcation  of  the  com- 
mon iliac  vessels  and  the  ureter,  and  run  iu  a  tortuous 
course  in  the  upper  border  of  the  broad  ligament,  or  more 
exactly  in  the  infundibulo-pelvic  ligament,  to  the  cornua  of 
the  uterus,  where  they  anastomose  with  the  uterine  arteries 
along  the  respective  sides. 

Each  ureter  crosses  the  common  iliac  artery  near  its 
bifurcation,  and  runs  from  behind  downward,  forward, 
and  inward  in  front  of  the  internal  iliac  artery  and  its 
anterior  division,  lying  in  the  base  of  the  broad  ligament, 
which  is  limited  by  the  levator  ani  muscle.  Near  the  level 
of  the  external  os  the  ureter  is  crossed  on  its  inner  side  by 
the  uterine  artery,  and  then  runs  aloug  the  side  of  the 
vagina  about  half  an  inch  from  the  cervix,  entering  the 
bladder  just  above  the  middle  of  the  anterior  vaginal  wall. 
The  uterine  artery  arises  from  the  anterior  trunk  of  the 
internal  iliac  near  the  synchondrosis,  and  passes  downward 
and  forward  to  a  point  just  above  the  spine  of  the  ischium, 
where  it  leaves  the  pelvic  wall,  but  still  descends  almost  to 
the  tuberosity  of  the  ischium ;  it  then  turns  up  toward  the 
vagina,  reaching  the  uterus  at  the  utero-vaginal  junction. 
Opposite  the  external  os  it  gives  off  the  circular  artery  of 
the  cervix  and  continues  along  the  side  of  the  uterus  be- 
tween the  layers  of  the  broad  ligament,  and  at  the  superior 
cornu  it  anastomoses  with  the  ovarian  artery. 

The  peritoneum  is  firmly  adherent  to  the  fundus  of  the 


576  OPERATIVE  SURGERV. 

uterus,  but  gradually  becomes  more  loosely  attached  uutil 
it  can  be  readily  stripped  up  with  the  finger  in  the  vesico- 
uterine depression.  Posteriorly  it  descends  about  three- 
quarters  of  an  inch  on  the  vaginal  wall,  and  is  likewise 
easily  peeled  off  to  the  same  level  as  in  front.  With  a 
normal  uterus  and  an  empty  bladder,  the  latter  lies  upon 
the  cervix  for  about  half  an  inch. 


OVAEIOTOMY. 

The  patient  is  prepared  in  the  usual  way  for  a  lapar- 
otomy, and  immediately  before  the  operation  she  is  cathe- 
terized,  the  sponges,  pads,  and  clamps  are  counted  and  the 
number  of  each  written  down.  An  incision  three  or  four 
inches  long  is  made  in  the  median  line  between  the  umbil- 
icus and  the  pubes,  which,  if  necesary,  is  later  extended 
upward  with  a  slight  semicircular  deviation,  including  the 
umbilicus  and  passing  to  the  left  of  it  to  avoid  the  falciform 
ligament.  The  incision  is  deepened  layer  by  layer  and  the 
peritoneum  first  opened  above  by  pinching  up  a  fold  with 
the  fingers  or  forceps  and  nicking  it,  and  then  enlarging  it 
downward  by  cutting  on  the  fingers  inside  as  a  director,  care 
being  taken  to  avoid  the  bladder,  which  is  usually  recogniz- 
able from  within  as  a  thickened  fold  lying  near  the  pubes. 

When  the  peritoneum  is  adherent  to  the  tumor  it  may 
be  simpler  to  prolong  the  incision  above  the  latter  to  make 
certain  that  the  abdominal  cavity  has  been  opened  and  that 
the  peritoneum  is  not  simply  stripped  from  the  parietes. 
Sometimes,  also,  the  bladder  is  drawn  far  up  above  its 
usual  position,  but  it  can  be  recognized  by  its  vascularity 
or  by  a  sound  passed  into  it  through  the  urethra.  A 
sponge  protective  packing  is  wedged  around  the  exposed 
cyst,  which  is  then  punctured  with  a  large  trocar  and  can- 
ula,  the  latter  being  provided  with  a  tube  to  conduct  the 
fluid  to  one  side,  and  as  soon  as  possible  the  walls  are 
grasped  by  the  fingers  or  by  forceps  and  drawn  into  the 
wound,  while,  at  the  same  time,  pressure  is  made  on  the 
parietes,  or  the  patient  is  rolled  on  one  side  to  favor  the 
escape  of  the  contents.  If  the  latter  are  too  thick  to  flow 
readily,  the  puncture  may  have  to  be  enlarged  sufficiently 


SPECIAL  OPERATIONS.  577 

to  permit  them  to  be  scooped  out  by  hand,  and  through 
this  opening  other  loculi  are  entered  by  the  finger,  knife, 
or  trocar,  and  enough  liquid  evacuated  to  permit  of  an  at- 
tempt to  turn  the  cyst  out  of  the  abdomen. 

The  adhesions  are  cautiously  separated  by  the  finger- 
nail and  blunt-pointed  scissors  or  divided  between  double 
catgut  ligatures ;  if  the  intestiue  is  torn  the  rent  must  be 
immediately  closed  by  Lembert's  sutures. 

The  peritoneal  cavity  must  be  constantly  protected  by 
the  addition  of  fresh  sponges  as  the  dissection  progresses, 
though  usually  no  harm  follows  from  the  escape  into  it 
of  some  of  the  cyst-contents.  When  the  pedicle  has 
been  fully  exposed,  often  by  bringing  the  cyst  out  of  the 
belly,  if  broad  it  is  secured  in  sections  by  the  interlocking 
silk  ligature  passed  on  a  blunt-pointed  aneurism  needle, 
and  the  tumor  or  what  remains  of  it  is  excised ;  or  the 
pedicle  may  be  divided  with  scissors  and  the  vessels  secured 
as  they  are  encountered  by  clamps,  and  after  removal  of 
the  tumor  ligated  separately. 

A  comparatively  small  pedicle  cau  be  ligated  en  masse 
with  stout  silk,  or  by  the  Staffordshire  knot,  in  which 
the  pedicle  is  transfixed  by  a  stout  silk  ligature  passed 
double  and  the  loop  drawn  back  over  the  tumor  to  lie  be- 
tween the  long  ends  of  the  ligature,  which  are  then  tied 
over  it. 

If  there  have  been  few  or  no  adhesions  and  the  cyst  has 
been  removed  practically  without  opening  it,  the  abdomi- 
nal wound  can  be  closed  entirely  in  the  usual  way,  after 
taking  out  and  counting  the  sponges  and  clamps.  But 
drainage  by  rubber  tubes  and  iodoform-gauze  packing  is 
imperative  whenever  there  is  even  a  possibility  of  infec- 
tion, and  especially  if  a  portion  of  the  cyst  wall  has  been 
necessarily  left  behind  owing  to  its  too  firm  adhesion 
to  important  structures.  If  there  has  been  much  peri- 
toneal laceration  accompanied  by  oozing  from  minute  blood- 
vessels, drainage  and  hemostasis  are  conveniently  provided 
for  by  a  large  sheet  of  iodoform  gauze  placed  in  contact 
with  the  lacerated  surface  and  having  all  its  edges  brought 
out  of  the  abdominal  wound. 

This  pouch  is  then  stuffed  with  strips  of  gauze  which 
are  subsequently  removed  one  by  one,  to  gradually  reduce 


578  OPERATIVE  SURGERY. 

its  bulk.     The   parietal  opening  is  partially   closed  aud 
dressed  antiseptically  in  the  usual  way. 


OOPHORECTOMY. 

This  term  is  used  to  designate  the  removal  of  macro- 
scopically  normal  ovaries  and  Fallopian  tubes  for  hemo- 
static or  analgesic  purposes. 

After  the  usual  preliminaries,  including  catheterization, 
the  patient  is  placed  in  Trendelenburg's  position,  which 
greatly  facilitates  all  intra-abdominal  operations  on  the 
pelvic  organs. 

A  convenient  extemporaneous  way  of  doing  this  is  to 
invert  a  chair  upon  the  table  and  lay  the  patient  upon  its 
back  so  that  her  knees  are  hooked  over  the  cross-bars  be- 
tween its  hind  legs. 

An  incision  about  three  inches  long  is  made  in  the  me- 
dian line  above  the  pubes,  and  deepened  layer  by  layer  till 
the  peritoneal  cavity  is  opened.  Two  fingers  are  passed 
through  the  incision  to  the  fundus  of  the  uterus  and  theuce 
outward,  following  one  Fallopian  tube  to  its  extremity, 
which  is  drawn  up  into  the  abdominal  wound  together 
with  the  ovary.  Flat  sponges  are  placed  around  them, 
and  a  stout  silk  ligature  is  passed  double  on  a  blunt-pointed 
aneurism  needle  through  the  broad  ligament  in  the  angle 
between  the  Fallopian  tube  and  the  uterus,  and  the  Staf- 
fordshire knot  is  made  and  tied  as  close  to  the  uterus  as 
possible,  with  care  to  get  beyond  the  ovary  and  not  leave 
any  portion  of  the  gland  in  its  grasp.  The  ovary  and  tube 
are  then  excised,  and  after  a  final  inspection  of  the  pedicle 
for  hemorrhage  it  is  dropped  back  into  the  abdomen. 

The  same  proceeding  is  repeated  upon  the  other  side,  the 
flat  sponges  are  removed,  and  finally  the  abdominal  inci- 
sion is  closed  tight  in  the  usual  way  and  dressed  without 
drainage. 


SPECIAL  OPERATIONS.  579 


SALPINGO-OOPHORECTOMY,  OR  THE  REMOVAL  OP  A  TUBE 
DISTENDED    WITH    PUS,    AND    ITS    OVARY. 

After  the  usual  preliminaries,  including  antiseptic  vaginal 
douches,  the  patient  is  catheterized  aud  placed  in  Trende- 
lenburg's position,  as  described  for  o5phorectomy,  and  if, 
at  the  same  time,  a  bougie  is  inserted  in  the  rectum,  it  may 
later  be  found  very  useful  for  mapping  out  its  position. 
An  incision  not  less  than  four  inches  long  is  made  in  the 
median  line  above  the  pubes,  afterward  extended,  if  neces- 
sary, around  the  umbilicus  to  afford  plenty  of  room  for 
manipulation.  The  incision  is  deepened  layer  by  layer, 
the  bleeding  stopped,  and  the  peritoneum  nicked  in  the 
upper  angle  of  the  wound  and  opened  downward  on  the 
finger  as  a  guide,  stopping  short  of  the  bladder,  which  can 
be  recognized  on  the  inside  as  a  thickened  fold  near  the 
pubes ;  or,  if  there  is  any  doubt,  by  a  sound  passed  through 
the  urethra.  The  omentum  and  intestines  are  pushed  back, 
separating  adhesions  with  the  finger-nail  or  blunt-pointed 
scissors,  till  there  is  a  full  exposure  of  the  uterus  and  its 
appendages,  which  are  then  surrounded  with  flat  sponges 
or  pads,  completely  shutting  off  the  rest  of  the  peritoneal 
cavity. 

The  fingers  are  passed  outward  from  the  fundus  of  the 
uterus,  following  every  crevice  around  first  one  tube  and 
then  the  other,  till  some  spot  is  found  where,  by  slight 
pressure  or  tearing,  the  tip  of  the  index-finger  can  be 
worked  under  or  around  the  mass  and  the  tube  freed,  gen- 
erally in  company  with  its  ovary.  If  pus  should  be  dis- 
covered escaping,  the  dissection  is  stopped  till  it  has  been 
entirely  sponged  away,  enlarging,  if  necessary,  the  hole 
from  which  it  comes.  The  somewhat  free  oozing  is  con- 
trolled by  sponge  packing,  and  when  a  more  or  less  dis- 
tinct pedicle  has  been  formed,  or  the  finger  recognizes  a 
dangerous  amount  of  resistance  to  its  progress,  the  strip- 
ping up  and  gently  tearing  process  is  stopped. 

With  a  blunt-pointed  aneurism  needle  a  stout  catgut 
ligature  is  then  passed  under  the  infundibulo-pelvic  liga- 
ment, or  the  outer  attachment  of  the  freed  mass  consisting 
of  the  ovary  and  diseased  tube,  tying  off  this  ligament 


580  OPERATIVE  SURGERY. 

close  to  the  mass  and  including  the  ovarian  artery,  the 
position  of  which  can  be  ascertained  in  advance  by  pal- 
pating the  broad  ligament  and  notiug  the  pulsation. 

Another  catgut  ligature  is  passed  through  the  broad  liga- 
ment in  the  angle  formed  by  the  junction  of  the  uterus  and 
Fallopian  tube,  and  the  latter  is  secured  with  the  termina- 
tion of  the  artery  close  to  the  uterus. 

Beginning  on  the  uterine  side  of  the  outer  ligature,  the 
tissues  attached  to  the  under  side  of  the  tube  are  cut  with 
blunt-pointed  scissors,  clamping  each  vessel  or  bleeding 
point  as  it  is  encountered,  and  in  this  way,  when  the  tube 
alone  is  diseased,  it  is  generally  easy  to  leave  the  ovary  un- 
disturbed, and  this  is  always  done  by  some  surgeons;  but 
in  such  an  instance  there  should  be  no  preliminary  ligature 
of  the  infundibulo-pelvic  ligament  with  the  ovarian  artery, 
and  the  scissors  must  be  kept  close  to  the  tube,  while  bleed- 
ing is  controlled  by  individual  ligature  of  each  vessel  as  it 
is  cut. 

The  diseased  mass  is  then  excised  on  the  distal  side  ot 
the  ligature  next  to  the  uterus  and  the  stump  disinfected. 
Before  its  division  the  tube  is  secured  by  a  clamp  to  pre- 
vent the  escape  of  pus  if  it  has  not  already  occurred. 

Ligature  en  masse  of  the  pedicle,  which  is  almost  always 
bulky,  is  only  mentioned  to  be  condemned.  After  chang- 
ing the  sponges  and  securing  any  vessels  which  still  bleed, 
the  cut  edges  of  peritoneum  forming  the  broad  ligament 
are  united  with  fine  catgut  sutures  over  the  deuuded  area 
which  lies  under  the  Fallopian  tube,  and  when  it  has  been 
possible  to  perform  the  operation  without  the  escape  of  a 
drop  of  pus,  and  without  leaving  a  large  oozing  surface, 
the  protective  sponges  are  removed  and  the  abdominal 
wound  closed  tight  in  the  usual  way. 

Otherwise  the  peritoneal  cavity  is  made  as  clean  and  dry 
as  possible  and  rubber  tubes  with  lateral  perforations  are 
placed  in  the  suspected  regions,  with  one  always  in 
Douglas's  pouch,  and  surrounded  by  strips  of  iodoform 
gauze,  around  the  ends  of  which  the  abdominal  wound  is 
partially  closed. 

Sometimes  the  Fallopian  tube  will  be  found  changed 
into  an  abscess  sac,  with  very  firm  adhesions,  which  only 
permit  the  sac  to  be  opened,  or  not  more  than  partially 


SPECIAL  OPERATIONS.  581 

removed  ;  very  rarely  it  can  be  only  partially  exposed,  but 
the  pus  can  always  be  reached  somewhere  by  a  careful  dis- 
section, aided  possibly  by  a  guiding  puncture  with  an 
aspirating  needle.  The  surrounding  parts  are  then  care- 
fully protected  by  a  sponge  packing  and  the  abscess  cavity 
thoroughly  evacuated  and  washed  out  with  boiled  water, 
and  drained  with  rubber  tubes  and  iodoform  gauze.  Com- 
munication between  the  abdominal  wound  and  the  opening 
in  the  sac,  which  may  be  at  a  distance  from  the  surface,  is 
maintained  by  packing,  which  should  also  extend  into  and 
protect  all  possibly  infected  regions  around  the  abscess. 
Aided  by  an  exploring  finger  in  the  vagina  it  will  some- 
times be  possible  and  very  advisable  to  force  a  blunt 
pointed  forceps  from  the  bottom  of  the  abscess  cavity  into 
the  posterior  foruix,  and  thus  pass  a  tube  to  afford  drain- 
age in  the  most  dependent  regions  as  well  as  from  the  sur- 
face of  the  abdomen.  The  vagina  is  packed  around  the 
tube  and  a  dressing  is  placed  on  the  vulva,  while  every  pre- 
caution is  taken  to  prevent  infection  from  the  urine  and 
feces. 

If  the  vermiform  appendix  is  found  involved  or 
adherent  to  a  diseased  tube,  as  often  happens,  it  should 
be  excised  at  the  same  time.  Whenever  in  a  case  in  which 
the  abdominal  wound  has  been  closed  tight  symptoms  of 
secondary  hemorrhage  appear,  the  diagnosis  should  be  at 
once  verified  by  untying  a  stitch  in  the  lower  angle  of  the 
wound  and  passing  a  small  sponge  on  a  holder  into 
Douglas's  pouch.  If  done  with  every  antiseptic  precaution 
this  exploration  is  free  from  danger,  even  if  no  hemorrhage 
is  found. 

TUMORS   LYING   BENEATH   THE   BROAD   LIGAMENT. 

An  opening  is  made  in  the  overlying  peritoneum  generally 
in  front  of  the  Fallopian  tube,  and  through  this  the  dissec- 
tion, guided  by  the  sense  of  touch,  is  carried  out  by  the  tip 
of  the  finger  tearing  through  the  loose  connective  tissue  sur- 
rounding the  capsule  of  the  tumor,  and  the  latter  enucleated. 
The  few  vessels  are  clamped  as  they  are  encountered  and 
tied  later,  and  drainage  is  provided  for  as  after  salpingo- 
odphorectomy. 


582  OPERATIVE  SURGERY. 


OPERATIONS  FOR  ECTOPIC  GESTATION. 

In  the  early  stages  of  this  condition  before  the  placenta 
has  formed,  the  operation  is  conducted,  according  to  the 
situation  of  the  mass,  in  the  same  way  as  in  ovariotomy  or 
salpingo-oophorectomy,  or  for  a  tumor  lying  below  the  broad 
ligament. 

Later,  after  the  formation  of  the  placenta,  the  general 
rule  is  to  open  the  abdomen  in  the  median  line  below  the 
umbilicus,  and,  after  protecting  the  peritoneal  cavity  by  a 
sponge  packing,  the  sac  is  entered  in  front  like  an  ovarian 
cyst,  avoiding  if  possible  the  site  of  the  placenta,  which  can 
usually  be  recognized  by  the  surrounding  vascularity.  But 
sometimes  the  placenta  may  have  to  be  perforated,  and  then 
the  hemorrhage  from  it  is  controlled  by  clamps  or  deep 
sutures. 

The  foetus  and  amniotic  liquid  are  extracted  while  the 
surrounding  parts  are  well  guarded,  and  when  it  seems  per- 
fectly feasible  the  sac  may  be  dissected  out  with  the  pla- 
centa, separating  adhesions  with  the  tip  of  the  finger  or 
bluut-pointed  scissors  and  arresting  the  bleeding  as  it 
occurs ;  but  more  often  the  complete  removal  is  impossible, 
and  the  opening  in  the  sac  is  either  stitched  to  the  margins 
of  the  abdominal  wound  or  kept  in  communication  with  it 
by  packing  and  drainage  applied  on  the  principles  already 
enunciated,  while  the  placenta  is  left  to  slough  away  with 
the  attached  umbilical  cord. 

If  the  operation  is  performed  for  hemorrhage  following 
rupture  of  an  extra-uterine  gestation,  the  abdomen  is  opened 
in  the  same  way  aud  one  hand  passed  to  the  fundus  of  the 
uterus  and  thence  outward  to  the  boggy  mass,  which,  if 
it  can  be  raised  to  the  surface,  is  easily  secured  and  treated. 
But  if  this  is  impossible,  an  attempt,  guided  by  the  hand 
inside  the  belly,  is  made  to  seize  one  or  both  extremities  of 
the  broad  ligament  with  its  contained  vessels,  by  long- 
bladed  clamps. 

The  blood  and  debris  are  then  rapidly  scooped  out  of  the 
peritoneal  cavity  and  a  search  is  made  for  bleeding  points, 
which  are  immediately  caught  and  tied,  and  then  a  decision 
can  be  made  as  to  extirpation  of  the  sac,  which  does  not 


SPECIAL  OPERATIONS. 


583 


differ  from  an  inherent  tube  or  an  ovarian  cyst,  except  that 
the  placenta  in  the  great  majority  of  cases  should  not  be 
disturbed. 

The  treatment  of  a  case  in  which  suppuration  has 
occurred  does  not  differ  from  that  of  an  intra-abdominal  or 
pelvic  abscess. 

HYSTEROPEXY. 

The  peritoneal  cavity  is  opened  by  a  median  incision  of 
about  three  inches  just  above  the  pubes,  and  the  fundus  of 
the  uterus  is  brought  up  to  the  abdominal  wall,  to  which  it 
is  fixed  by  a  couple  of  silk  or  silkworm-gut  sutures  passed 
through  all  the  tissues  on  each  side  of  the  wound,  and 
through  the  muscular  tissue  of  the  fundus  of  the  uterus, 

Fig.  331. 


Hysteropexy.    Wylie's  method  of  shortening  the  round  ligaments. 

including  about  three-quarters  of  a  square  inch  of  the  peri- 
toneal coat.  Other  sutures  are  placed  in  the  wound  above 
and  below,  which  is  thus  closed  tight  without  drainage 
when  all  are  tied. 

The  fundus  of  the  uterus  may  be  previously  scraped  or 
scratched  to  promote  adhesions,  and  Wylie1  shortens  the 
round  ligaments  by  throwing  a  suture  around  a  loop  of  each 
in  the  abdomen  (Fig.  331). 


1  Amer.  Journ.  Obst.,  1889,  p.  478. 


584  OPERATIVE  SURGERY. 


Alexander's  operation1  for  shortening  the 
round  ligaments. 

With  every  antiseptic  precaution  an  oblique  incision  an 
inch  and  a  half  or  two  inches  long  is  made  over  the 
inguinal  canal  terminating  near  the  spiue  of  the  pubis. 
The  exterual  abdomiual  ring  is  cleared  and  the  inter- 
columnar  fascia  is  divided,  exposing  the  fine  yellow  fat  in 
which  the  reddish  cord-like  round  ligament  will  be  found 
near  the  upper  limit  of  the  external  abdominal  ring.  The 
other  side  is  treated  in  the  same  manner. 

A  slight  dissection  may  be  necessary  to  isolate  the 
round  ligament,  and,  aided  by  a  sound  in  the  cavity  of  the 
uterus,  enough  tractiou  is  made  on  the  cords  to  raise  the 
uterus  to  the  desired  position.  Often  four  or  five  inches  of 
the  round  ligament  can  thus  be  easily  drawn  out  through 
the  ring. 

The  ligaments  on  each  side  are  held  in  their  new  position 
by  a  couple  of  sutures  of  catgut  or  silkworm-gut  passed 
through  them  and  the  external  and  internal  pillars  of  each 
ring.  The  wound  in  the  intercolumnar  fascia  is  closed  with 
fine  catgut  and  the  external  wound  is  sutured  and  dressed 
antiseptically  without  drainage. 

Tampons  or  pessaries  must  be  worn  for  a  month. 


LAPARO-HYSTEROTOMY. 

By  this  term  is  meant  the  making  of  an  opening  into 
the  cavity  of  the  uterus  for  any  purpose,  commonly  the  ex- 
traction of  a  foetus.  In  the  latter  instance  the  time  of  elec- 
tion, according  to  Senn,2  is  during  the  first  stage  of  labor. 

The  patient  is  catheterized,  and  with  every  antiseptic 
precaution,  including  preliminary  antiseptic  douches  for  the 
vagina,  an  incision  about  six  inches  long  is  made  in  the 
median  line  above  the  pubes,  and,  bearing  in  mind  that  the 
abdominal  wall  is  apt  to  be  very  thin  and  that  the  enlarged 
uterus   is  in   contact  with   it  without  the   interposition  of 

1  Liverpool  Med.-Chir.  Journ.,  January,  1888,  p.  118, 

"  Amer.  Journ.  Med.  Sci.,  Sept.  1893. 


SPECIAL  OPERATIONS. 


585 


other  viscera,  the  incision  is  cautiously  deepened  layer  by 
layer  till  the  peritoueal  cavity  is  opened  in  the  whole  ex- 
tent of  the  wound  and  the  surface  of  the  uterus  exposed. 

Sponges  are  packed  around  the  latter  and  a  longitudinal 
incision  about  an  inch  long  is  made  in  its  anterior  wall  at  a 
point  midway  between  the  junction  of  the  Fallopian  tubes 
with  the  uterus.  To  lessen  the  hemorrhage  this  incision  is 
enlarged  downward  by  tearing  sufficiently  to  extract  the 
child,  head  first,  which  must  be  done  as  rapidly  as  possible 
after  rupturing  the  membranes.  As  the  bleeding  is  worst 
from  the  cervical  region,  the  rent  must  not  approach  this 
too  closely. 

Fig.  332. 


Closure  of  the  uterine  wound  after  Csesarean  section. 
B.  Muscular  wall  of  the  uterus. 


A,  Peritoneum. 


The  uterus  is  immediately  turned  out  of  the  abdomen, 
which  is  then  protected  by  a  warm  towel  and  its  neck  be- 
low the  opening  constricted  by  an  elastic  ligature  secured 
by  a  clamp  tightly  enough  to  arrest  the  bleeding.  The 
placenta  is  next  peeled  off  with  its  attached  membranes, 
and  after  cleansing  the  interior  of  the  uterus  the  rent  is 
closed  by  a  row  of  interrupted  stout  catgut  sutures  passed 
at  intervals  of  half  an  inch  through  the  entire  thickness  of 
the  uterine  wall,  exclusive  of  the  peritoneum,  and  about 
half  an  inch  from  the  torn  edge. 

Another  row  of  sutures  is  placed  between  these  in  the 
same  way,  but  including  only  half  the  muscular  thickness, 
and  these  are  covered  in  by  a  row  of  catgut  Lembert 
sutures,  which  should  pass  through  enough  of  the  muscular 
tissue  to  secure  good  peritoneal  apposition  over  the  line  of 
suture.     (Fig.  332.) 


586  OPERATIVE  SURGERY. 

The  abdominal  cavity  is  cleansed  and  the  elastic  ligature 
removed  from  the  uterus,  but  the  latter  is  not  replaced 
in  the  belly  until  after  contraction  has  occurred  or  been 
induced  by  pressure,  rubbing,  or  the  subcutaneous  injec- 
tion of  ergot.  The  abdominal  wound  is  then  closed  tight 
in  the  usual  way  and  dressed  without  drainage,  and  an 
iodoform-gauze  packing  is  placed  in  the  interior  of  the 
uterus  from  the  vagina. 

SYMPHYSIOTOMY.1 

The  patient  is  catheterized,  and,  after  thorough  disinfec- 
tion of  the  abdominal  wall  and  the  external  genitals,  a 
longitudinal  incision  two  or  three  inches  long  is  made  over 
the  symphysis  and  carried  down  to  the  bone. 

The  origin  of  one  pyramidalis  muscle  is  divided  suffi- 
ciently to  admit  the  index-finger,  which  is  inserted  behind 
the  pubes,  separating  and  pushing  back  from  the  bone  the 
prevesical  tissues,  aud  on  this  finger  as  a  guide  the  sym- 
physis, which  usually  is  not  exactly  in  the  middle  line,  is 
divided  by  a  probe-pointed  cartilage  knife  from  above  and 
behind  downward  and  forward,  sparing  if  possible  theliga- 
mentum  arcuatum  or  triangular  ligament.  A  sound  is 
sometimes  first  placed  in  the  urethra  and  bladder  to  draw 
them  to  one  side. 

After  extraction  of  the  child,  per  vias  uaturales,  the  pubic 
bones  can  be  reunited  by  buried  silk  sutures,  or  the  wound 
may  be  closed  by  silk  sutures  passed  through  the  skin  and 
the  anterior  portion  of  the  symphysis.  But  it  will  gener- 
ally be  found  sufficient  to  insert  simple  superficial  sutures, 
and,  after  dressing  the  wound  antiseptically,  to  immobilize 
the  pelvis  by  a  stout  binder  or  bandage. 


MYOMECTOMY,  OR   THE    REMOVAL    OF  A  SUBPERITONEAL, 
"  FIBROID  "    TUMOR    OF   THE    UTERUS. 

The  abdomen  is  opened  as  usual  in  the  median  line  be- 
low the  umbilicus  sufficiently  to  admit  the  hand,  and  after 

i  Morisani  ;   Ann.  de  (iynec.  et  d'Obst.,  April,  1892,  p.  241.    Oharpentier:  Bull. 
de  I'Acad.  de  Mod.,  March,  18>Jii,  p.  852, 


SPECIAL  OPERATIONS.  587 

exploration  the  incision  is  enlarged  if  necessary,  and 
adhesions  carefully  separated  or  divided  between  double 
catgut  ligatures.  The  rest  of  the  peritoneal  cavity  is  shut 
off  by  a  sponge  protective  packing,  and  when  the  growth 
has  a  distinct  pedicle  the  latter  is  simply  surrounded  by  a 
silk  ligature  which  may  in  addition  first  transfix  the  pedicle 
if  it  is  large,  and  the  growth  is  excised ;  or,  when  there  is 
no  pedicle  and  the  tumor  is  sharply  defined,  two  semilunar 
flaps  are  cut  from  the  peritoneum  on  its  base,  and  through 
the  gap  thus  made  the  tumor  enucleated  by  the  tip  of  the 
finger  or  blunt-pointed  scissors. 

The  vessels,  which  are  principally  superficial,  are  clamped 
and  tied  as  they  are  encountered,  and  if  there  is  bleeding 
from  vessels  buried  in  the  base  it  can  be  controlled  by  a 
deep  catgut  suture  passed  on  a  curved  needle. 

The  peritoneal  flaps  are  closed  over  the  denuded  sur- 
face with  fine  catgut,  and  if  it  seems  advisable  after 
removal  of  the  sponge  protectives  an  iodoform-gauze 
packing  is  placed  in  contact  with  any  region  where  hemor- 
rhage or  infection  is  possible,  and  the  abdominal  wound  is 
partially  closed  around  the  ends  of  the  gauze.  When  all 
goes  well  this  packing  is  removed  after  twenty-four  or  forty- 
eight  hours,  and  the  wound  is  then  closed  tight  for  secondary 
union  by  a  stitch  inserted  for  this  purpose  at  the  time  of 
the  operation. 


ABDOMINAL    HYSTERECTOMY. 

If  the  uterus  is  comparatively  normal,  there  is  no  un- 
usual difficulty  about  this  operation. 

After  rendering  the  vagina  aseptic,  the  patient  is 
catheterized  and  placed  in  Trendelenburg's  position  and  a 
median  incision  about  eight  inches  long  is  made  above  the 
pubes  and  deepened  layer  by  layer  till  the  abdomen  is 
opened.  The  intestines  are  covered  and  pushed  back  from 
the  pelvis  by  flat  sponges  or  pads,  and  the  Fallopian  tube 
and  utero-ovarian  and  round  ligaments  are  secured  together 
on  each  side  close  to  the  uterus  by  a  double  ligature  of 
stout  catgut  passed  through  the  broad  ligament  under  these 
structures  on  an  aneurism  needle.     Then  the  pulsations  of 


588  OPERATIVE  SURGERY. 

the  uterine  arteries  are  felt  for  at  the  sides  of  the  cervix, 
aud  each  artery  is  ligated  near  the  vault  of  the  vagina  by 
stout  catgut  passed  through  an  incision  in  the  peritoneum 
on  an  aneurism  needle,  which  must  be  kept  as  close  to  the 
artery  as  possible.  Starting  at  the  cornu,  the  tissues  are 
divided  between  the  double  ligatures,  and  each  broad  liga- 
ment is  cut  at  the  lateral  border  of  the  uterus  as  low  as 
the  utero- vesical  fold  of  peritoneum,  which  is  divided 
transversely  by  cutting  toward  the  uterus  and  hugging 
close  to  the  cervix ;  with  short  snips  of  the  scissors  the 
anterior  fornix  of  the  vagina  is  entered. 

Posteriorly,  the  peritoneum  is  cut  transversely  at  the 
level  of  the  internal  os  or  a  little  lower,  and  the  posterior 
fornix  is  entered  like  the  anterior  and  the  uterus  removed. 
After  tying  the  bleeding  points,  which  are  few,  a  rubber 
drainage  tube  and  iodoform-gauze  packing  are  passed  from 
the  abdominal  wound  out  through  the  vagina,  leaving  the 
internal  extremities  in  contact  with  the  stumps  of  the  tubes 
and  the  opening  made  in  the  vagina,  and  not  communicat- 
ing with  the  abdominal  wound,  which  is  then  closed  tight 
in  the  usual  way  and  dressed  without  drainage.  An  an- 
tiseptic dressing  is  placed  over  the  termination  of  the  tube 
and  packing  at  the  vulva,  and  every  precaution  taken  to 
prevent  infection  by  the  urine  or  feces. 

It  may  often  be  desirable  to  divide  the  outer  instead  of 
the  inner  end  of  the  broad  ligament  between  a  double  cat- 
gut ligature,  and,  after  securiug  the  uterine  artery  at  the 
cervix,  to  free  the  tubes  aud  ovaries  by  cutting  close  beneath 
them,  as  formerly  described,  and  then,  following  the  sides 
of  the  uterus,  to  excise  the  latter,  together  with  the 
appendages. 

If  the  uterus  has  become  greatly  altered  by  the  growth 
of  a  tumor,  no  description  can  be  given  which  is  applicable 
to  all  cases.  The  abdomen  is  opened  by  a  median  incision 
which  may  have  to  be  prolonged  from  the  symphysis  to 
the  ensiform  process,  and  the  limits  of  the  bladder,  which 
is  apt  to  be  drawn  above  its  usual  position,  are  ascertained 
by  a  sound  in  the  urethra  if  necessary.  Adhesions,  which 
may  exist  between  the  tumor  and  any  abdominal  viscus, 
are  carefully  separated  or  divided  between  double  catgut 
ligatures,  and  the  mass  is  gradually  lifted  out  of  the  belly 


SPECIAL  OPERATIONS.  589 

by  a  hand  placed  beneath  it,  ascertaining  its  counectious 
and  the  position  of  the  ovaries,  tubes,  and  the  broad  liga- 
ments, and  the  cavity  is  immediately  protected  by  a  sponge 
packing  or  warm  towels. 

It  may  be  possible  to  follow  the  formal  method  of  re- 
moval already  given,  but  otherwise  the  enlarged  uterus  is 
transfixed  below  by  a  couple  of  pins  made  for  the  purpose 
with  guarded  points,  and  under  these,  which  prevent  it 
slipping,  an  elastic  tourniquet  or  ecraseur  is  applied, 
including  both  broad  ligaments,  with  due  regard  for  the 
position  of  the  bladder  ;  frequently  a  smaller  pedicle  can 
or  must  be  manufactured,  generally  by  dividing  the  broad 
ligaments  in  sections  between  double  catgut  ligatures.  The 
mass  distal  to  the  tourniquet  is  then  excised  and  the  cervical 
canal  disinfected  by  a  drop  of  pure  carbolic  acid. 

If  the  stump  is  to  be  treated  extra-peritoneally,  it  is  left 
in  the  lower  angle  of  the  wound  with  the  tourniquet  in 
place  and  the  pins  resting  on  the  surface  of  the  abdomen  ; 
the  protective  packing  with  blood  clots,  etc.,  is  removed  ; 
and  the  wound  is  closed  in  the  usual  way  around  the 
stump,  with  care  to  secure  peritoneal  apposition,  if  necessary, 
by  sutures  below  the  ligatures. 

Sometimes  the  pins  may  have  to  be  withdrawn  from  the 
stump  and  the  latter  fixed  at  the  level  of  the  parietal 
peritoneum,  where  it  can  be  retained  by  a  couple  of  silk 
sutures  through  the  abdominal  wall  on  each  side  of  the 
wound,  which  is  then  closed  above  and  below  around  a 
packing  placed  in  contact  with  the  stump  and  its  edges. 

If  the  pedicle  is  to  be  treated  by  the  intra-peritoneal 
method,  the  base  of  the  growth  is  cut  in  the  form  of  a  cone 
or  triangle  with  its  apex  in  the  cervical  canal  at  the  level  of 
the  rubber  tourniquet,  and,  after  disinfecting  the  canal  and 
securing  the  open  mouths  of  any  vessels  in  sight,  the 
peritoneal  margins  of  the  stump  are  united  with  catgut,  the 
tourniquet  removed,  and  deep  catgut  sutures  placed  to 
arrest  whatever  bleeding  follows.  The  stump  is  then 
dropped  back  into  the  abdomen,  and  the  latter  cleansed, 
drawing  the  peritoneum  as  far  as  possible  over  any  exposed 
raw  surfaces,  and  the  parietal  wound  is  closed  around 
drainage  carried  down  to  the  stump,  or  it  is  closed  tight 
without  drainage. 

26 


590  OPERATIVE  SURGERY. 

It  is  always  advisable,  when  practicable,  to  place 
independent  catgut  ligatures  upon  the  ovarian  arteries. 
Ligatures  en  masse  are  so  apt  to  slip,  and  dangerous 
hemorrhage  is  so  frequent  an  accident  after  their  use,  that 
if  the  condition  of  the  patient  permit  the  attempt  should 
always  be  made  to  secure  vessels  on  the  cut  surface  of  the 
pedicle  and  then  remove  the  ligature  en  masse. 

Amputation  of  the  Gravid  Uterus.  (Poito's  Operation.) 
In  a  true  Porro's  operation  the  foetus  is  viable  and  is 
extracted  before  the  uterus  is  excised.  The  abdomen  is 
opened  and  the  fcetus  removed  as  described  for  lapaix)- 
hysterotomy,  except  that  the  longitudinal  direction  of  the 
uterine  incision  is  of  less  consequence.  In  Midler's  modi- 
fication the  parietal  incision  is  made  sufficiently  long  to 
permit  the  uterus  to  be  turned  out  of  the  abdomen  before 
the  child  is  removed. 

After  tying  the  cord  the  uterus  is  immediately  lifted  out 
of  the  belly  and  an  elastic  ligature  or  ecraseur  is  thrown 
around  the  cervix  and  broad  ligaments.  The  uterus  with 
the  ovaries  and  tubes  is  then  amputated  transversely  about 
three-quarters  of  an  inch  above  the  constrictiou,  and  the 
stump  is  fastened  in  the  lower  angle  of  the  wound  by  a 
couple  of  pins  transfixing  it  distal  to  the  ligature  and  rest- 
ing on  the  skin  with  the  poiuts  protected.  The  abdominal 
cavity  is  cleansed  and  the  protective  sponges  are  removed 
and  the  wound  is  closed  in  the  usual  way  around  the 
stump,  stitching  the  edges  of  the  peritoneum  with  catgut 
to  the  uterine  peritoneum  below  the  constricting  band, 
though  this  is  not  always  necessary. 

In  this,  as  in  similar  operations,  it  is  advisable  to  place 
two  dressings  on  the  wound,  the  upper  to  remain  undis- 
turbed, while  the  lower,  covering  the  sloughing  pedicle,  is 
changed  as  often  as  required. 

Vaf/inal  Hysterectomy.  The  patient  is  catheterized  and 
placed  in  the  lithotomy  position  and  the  external  genitals 
are  thoroughly  disinfected.  The  vagina  is  held  open  by 
broad  retractors  and  the  uterus  is  pulled  down  by  vol- 
sella  forceps  grasping  the  cervix,  while  the  adjoining 
mucous  membrane  is  cut  well  clear  of  the  disease  bv  blunt- 


SPECIAL  OPERATIONS.  591 

pointed  scissors.  Keeping  close  to  the  uterus  the  dissection 
is  contiuued  on  its  anterior  and  posterior  surface  by  the  tip 
of  the  finger  aud  short  snips  of  the  scissors,  but  at  the 
sides,  after  division  of  the  mucous  membrane,  the  cellular 
tissue  is  simply  pushed  up  as  high  as  possible,  or  till  the 
pulsatious  of  the  uterine  artery  are  felt.  The  finger  is 
finally  thrust  through  the  utero-vesical  fold  of  peritoneum, 
and  after  cleansing  the  vagina  of  clots  aud  debris  flat 
sponges  are  poked  in  around  the  uterus. 

Douglas's  pouch  is  entered  in  the  same  manner,  con- 
trolling the  hemorrhage  from  the  vaginal  wound  by  a  few 
catgut  sutures  through  its  cut  edges,  and  then  the  finger  is 
hooked  over  the  fundus,  pulling  it  down  into  the  posterior 
opening  and  thus  bringing  within  reach  the  upper  border 
of  the  broad  ligaments,  which  are  seized  by  long-bladed 
clamps  and  divided  on  the  uterine  side.  Guided  by  the 
finger,  other  clamps  are  placed  on  the  remaining  tissues 
close  to  the  uterus,  which  is  then  excised. 

Injury  to  the  ureters  is  avoided  by  thorough  separation 
of  the  lower  lateral  cellular  tissue  early  in  the  operation, 
the  ureters  being  pressed  forward  with  the  anterior  layer 
of  the  broad  ligament.  Richelot1  leaves  the  clamps  in 
place  for  twenty-four  to  forty-eight  hours,  but  whenever 
possible  it  is  better  to  secure  with  a  silk  ligature,  at  a 
proper  distance  from  the  clamps,  the  tissues  in  the  grasp  of 
each  before  they  are  severed  from  the  uterus.  Then  if  the 
adnexa  can  be  separated  and  drawn  down  the  pedicle  of 
each  may  be  secured  with  one  or  more  clamps,  which  can 
be  either  left  in  place  or  the  tissues  in  their  grasp  can  be 
ligated  with  silk  and  the  ovaries  and  tubes  thus  excised. 

A  rubber  drainage  tube  surrounded  by  iodoform-gauze 
packing  is  placed'  in  the  vaginal  wound  and  covered  by  an 
antiseptic  dressing  on  the  vulva. 


AMPUTATION    OF   CERVIX    UTERI. 

Infra-vaginal.     The  cervix  may  be  removed  with  the 
bistoury  or  scissors,  the  ecraseur,  or  the  galvano-cautery ; 

1  Annals  of  Surgery,  September,  1893,  p.  33 


592 


OPERA TIVE  S  UBQER  Y. 


flaps  may  be  made  and  united  as  shown  in  Fig.  333.  In 
the  latter  the  cervix  is  split  transversely  from  below  up. 
The  patient  is  placed  in  Sims's  position,  the  speculum  in- 
troduced, the  cervix  slit  transversely,  and  each  lip  seized 
in  turn  with  forceps,  and  cut  off  as  near  the  vagiual  junc- 
tion as  is  considered  proper.     The  mucous  membraue  of 


Fig.  333. 


A.  B. 

Amputation  of  the  cervix  with  double  Haps.    (Simon.) 

A.  Sectional  view  showing  lines  of  incision  for  formation  of  Haps  and  method 
of  suture. 

B.  Front  view  of  cervix,  operation  complete.    (Pozzi.) 


the  interior  is  then  drawn  down  and  made  fast  with  silver 
sutures  to  the  outer  edge  of  the  cervix  so  as  to  cover  iu  the 
raw  surface.     The  hemorrhage  is  often  very  severe. 

Hapra-v(i//hud.  After  thorough  disinfection  of  the  ex- 
ternal and  internal  genitals  the  patient  is  placed  in  the 
lithotomy  position  and  the  cervix  is  grasped  by  a  volsella 
forceps.  The  mucous  membrane  around  the  cervix  well 
clear  of  the  disease  is  divided  by  scissors  curved  on  the 


SPECIAL  OPERATIONS. 


593 


flat,  and,  keeping  close  to  the  uterus,  the  mucous  membrane 
is  dissected  or  peeled  off  with  the  left  forefinger  and  the 
scissors  in  front  and  behind,  but  at  the  sides,  after  the  first 
incision  of  the  mucous  membrane,  the  cellular  tissue  between 
the  broad  ligaments  is  simply  pushed  aside. 

When  a  point  is  thus  reached  in  front  and  behind  where 
the  peritoneum  ceases  to  strip  up  readily,  guided  by  the 
finger,  the  structures  within  the  broad  ligaments  are  seized 
by  long-bladed  clamps  close  to  the  uterus  and  divided  on 


Fig.  334. 


Amputation  of  cervix  by  one  flap  or  excision  of  the  mucosa. 
(Schroeder's  operation.) 

A.  Showing  method  of  placing  the  sutures.  (1  and  2  are  those  uniting  the  com- 
missures.) 

B.  Section  showing  shape  of  incisions  (e  f)  and  (b  c)  line  of  suture. 

C.  Shows  position  of  flaps  after  suturing. 


the  uterine  side.  The  uterus  can  then  probably  be  dragged 
lower,  and,  with  a  sound  in  the  canal,  the  uterine  tissue  is 
cut  obliquely  upward  from  the  exterior  to  the  sound,  while 
the  finger  protects  the  surrounding  parts,  and  in  this 
way  the  cervix  and  a  considerable  portion  of  the  body  of 
the  uterus  is  removed.  A  packing  of  iodoform  gauze  is 
placed  in  the  vagina  in  contact  with  the  cut  surface,  and 

26* 


594  OPERATIVE  SURGERY. 

the  clamps  are  left  in  place  for  twenty-four  to  forty-eight 
hours,  when  they  can  be  removed  without  disturbing  the 
packing. 

Schroede^s  Flap  Operation  for  the  Removal  of  Diseased 
Cervical  Mucous  Membrane.  The  cervix  is  split  trans- 
versely from  below  up  to  the  vault  of  the  vagina  and  the 
front  and  back  halves  thus  formed  retracted.  The  mucous 
membrane  and  underlying  tissue  are  then  removed  from  the 
lower  part  of  the  cervical  canal,  as  shown  in  Fig.  334,  B 
f,  e,  d.  After  this  the  remaining  external  part  of  the  cer- 
vix (Fig.  334,  B,  x)  is  folded  in  and  sutured  over  the  raw 
surface,  as  illustrated  in  Fig.  334,  A  and  C.  The  opera- 
tion is  concluded  by  uniting  the  lateral  commissures  (Fig. 
334,  A,  1  and  2). 


INDEX. 


ABDOMEN,  operations  on,  385 
paracentesis  of,  385 
Alexander's  operation,  584 
Amputations,  68 

circular  method,  69 

flap  methods,  70 
Teale,  71,  107 

oval  method,  70,  119 
Anaesthesia,  general,  13 

local,  14 

rectal,  16 
Anastomosis,  intestinal,  396 
Ankle,  amputation  at,  95 

excision,  155 

osteoplastic,  159 
Antrum,  trephining,  216 
Anus,  closure  of  artificial,  407 

excision  of,  453 

fistula,  452 

imperforate,  447 
Aorta,  ligature  of  abdominal,  54 
Appendix,  removal  of  vermiform,  409 
Arm,  amputation,  80 

with  scapula,  85 
Arteries,  ligature  of,  30 
Astragalus,  excision,  157, 196 
Atresia  vaginre,  546 
Axillary  artery,  ligature,  41 


BASSINI,  inguinal  hernia.  439 
Bladder  catheterization,  516,  543 
exstrophy,  514 
puncture,  518 
tumors,  539 
Blepharoplasty,  293 
BlepharoraphV,  291 
Birth-mark,  242 
Brachial  artery,  ligature,  43 

plexus,  227 
Brain,  topography,  203 
abscess,  211 
ventricles,  213 
Breast,  amputation  of,  382 
Broad  ligament,  tumors  of,  581 
Bronchotomy,  363 
Buccal  nerve,  225 


pALCANEUM,  excision,  193 

\J    Canthoplasty,  292 

Carotid,  ligature  of  common,  47 

of  external,  48 

of  internal,  51 
Castration,  483,  539 


Cataract,  depression  or  couching,  31S 

division  or  solution,  319 

extraction,  321 

operations  for,  317 
Catheterization,  female  bladder,  543 

male  bladder,  516 
Cervical  glands,  247 

plexus,  228 
Cervix,  amputation  of,  591 

lacerated,  571 

posterior  section,  573 
Cheiloplasty,  263 
Cholecystectomy,  469 
Cholecystenterostomy,  467 
Cholecystostomy,  465 
Chopart's  amputation,  92 
Circumcision,  490 
Clavicle,  excision,  182 
Cleft  palate,  351 
Coccyx,  excision,  189 
Colotomy,  403 

left,  inguinal,  403 

lumbar,  405 
Colporrhaphy,  570 
Corelysis,  316 

Cornea,  operations  on,  307 
Crural  nerve,  anterior,  232 
Cuneiform  osteotomy  for  talipes,  253 
Cystotomy,  supra-pubic,  534 


DORSALIS  pedis,  ligature,  65 
Dressings,  preparation  of,  21 
Dupuytren's  contraction,  245 

EAR,  operations  on,  340 
Ectopic  gestation,  582 
Ectropion,  293 
Elbow,  amputation  at,  7S 

excision,  131 

of  anchylosed,  13S 

reduction  of  dislocated,  139 
Elytrorrhaphy,  567 

posterior,  570 
Enterorrhaphy,  circular,  392 
Enterotomy,  402 
Entropion,  300 
Epispadias,  494 
Erectile  tumors,  240 
Estlander,  resection  of  ribs,  181 
Eustachian  tube,  341 
Excision  of  joints  and  bones,  124 
Exstrophy  of  bladder,  514 
Eye,  operations  on,  307 


596 


INDEX. 


Eyeball,  enucleation,  335 
Eyelids,  plastic  operations,  291 

FACIAL  artery,  ligature,  53 
nerve,  227 
Femoral  artery,  ligature,  60 
Femur,  creation  of  false  joint,  150 

excision  of  head,  146 
of  shaft,  189 

division  of  neck,  151 

osteotomy,  249 
Fibula,  resection,  191 
Fifth  nerve,  extra-cranial  resection,  217 

intra-cranial  resection,  215 
Fingers,  amputation,  72 

Dupuytren's  contraction,  245 

web,  234 
Fistula  in  ano,  452 

salivary.  361 

urethral,  503 

vesico-vaginal,  559,  565 
Foot,  amputations,  90-102 

excision  of  bones,  193 
Forearm,  amputation,  76 
Fracture,  operation  for  ununited,  256 
Frsenum  of  tongue,  361 

of  penis,  494 
Frontal  sinus,  216 


Innominate  artery,  ligature,  34 
Inferior  dental  nerve,  222 
Inferior  thyroid  artery,  ligature,  39 
Intestines, "anastomosis,  396 

operations  on,  389 

suture  of,  391 
Iridectomy,  311 
Iridesis,  315 
Iridotomy,  310 
Iris,  operations  on,  310 
Ischa-mia,  artificial,  19 


[AW,  anchylosis  of,  179 


KELOTOMY,  426 
Kidney,  methods  of  exposure,  471 
operations  on,  470 
Knee,  amputation  at,  110 
through  the  condyles,  111 
Carden,  111 
Gritti,  112 
disarticulation,  110 
excision,  152 
Kolpokleisis,  565 
Kraske,  excision  of  rectum,  458 


GALL-BLADDER,  operations  on,  465 
Gastro-enterostomy,  423 
Gastrorrhaphy,  420 
Gastrostomy,  413 
Gastrotomy,  416 

Genito-urinary  operations  in  female,  543 
Glands,  cervical,  247 
Gluteal  artery,  ligature,  59 
Goitre,  operations  lor,  378 
Gritti,  amputation  at  knee,  112 
Guyon,  amputation  of  leg,  105 

HALLUX  valgus,  252 
Halsted,  inguinal  hernia,  414 
Harelip,  273 

complicated,  276 
double,  276 
Hemorrhage,  arrest,  17 
Hemorrhoids,  453 
Hernia,  radical  cure  of  femoral, 
inguinal,  437 
umbilical,  445 
strangulated  femoral,  434 
inguinal,  482 
obturator,  437 
umbilical,  435 
Herniotomy,  426 
Hip,  amputation  at,  117 
Hip-joint,  excision,  146 

anchylosis,  150 
Humerus,  resection,  186 
Hydrocele,  485 
Hypospadias,  498 
Hysterectomy,  abdominal,  587 

vaginal,  590 
Hysteropexy,  583 

ILIAC  artery,  ligature  of  common,  65 
or  external,  58 
of  internal,  57 


LACHRYMAL  apparatus,  336 
gland,  removal,  336 

sac  and  duct,  337 
Laminectomy,  259 
Laparo-hysterotomy,  584 
Laparotomy,  386 
Laryngectomy,  370 
Laryngotomy,  363 

cricothyroid,  365 

thyroid,  365 
Leg,  amputation,  102 
Lingual  artery,  ligature,  51 

nerve,  226 
Litholapaxy,  518 
Lithotomy,  524 

lateral,  527 

median,  532 

supra-pubic,  534 

in  female,  545 
Liver,  operations  on,  461 

hydatids  of,  464 


MASTOID  cells,  342 
Maxilla,  inferior,  anchylosis,  179 
excision,  174 
superior,  excision,  102 
temporary,  169 
McBurney,  appendix,  410 
inguinal  hernia,  444 
Median  nerve,  230 
Medio-tarea]  amputation,  92 
Metacarpal  bone,  amputation,  74 

excision,  188 
Metatarsal  bone,  amputation,  89 

excision,  197 
Mikulicz,  excision  of  heel,  159 
Month,  operation  on,  344 
Musculospiral  nerve,  251 
Myomectomy,  586 


INDEX. 


597 


NASOPHARYNGEAL  polyp,  169 
Neck,  operations  on,  363 
Nephrectomy,  abdominal,  477 

lumbar,  476 
Nephrolithotomy,  475 
Nephropexy,  479 
Nephrotomy,  474 
Neurorrhaphy,  232 
Neurotomy,  217 
Nose,  plastic  operations,  278 


OCCIPITAL  artery,  ligature,  53 
CEsophagotomy,  375 
Olecranon,  suture,  258 
Oophorectomy,  578 
Operation,  conduct  of,  27 

preparation  for,  27 
Osteotomy,  249 

cuneiform,  for  talipes,  253 

for  hallux  valgus,  252 

of  femur,  249 

of  tibia,  252 
Ovariotomy,  576 


PALATE,  cleft,  351 

I     Patella,  suture  of,  257 

Paracentesis,  abdomen,  385 

thorax.  383 

pericardium,  384 
Pariphymosis,  493 
Pelvis,  resection  of  bones,  188 
Penis,  amputation  of,  488 
Pericardium,  paracentesis,  384 
Perineorrhaphy,  547 

Hegar,  552 
Perineum,  laceration,  553,  558 
Phalanges,  contraction  of,  244 

excision,  188,  197 
Phimosis,  489 
Pharyngotomy,  372 

subhyoid,  363 
Pirogoff,  amputation  at  ankle,  99 
Plastic  operations,  261 

eyelids,  291 

lip,  263,  271 

mouth,  270 

nose,  278 
Popliteal  artery,  ligature,  62 

nerve, 232 
Pott's  fracture,  reduction  of  old,  lfil 
Preparation  for  operation,  27 
Prostatectomy,  538 
Ptervgion,  305 
Pudic  artery,  ligature,  59 
Pylorectomy,  421 
Pylorus,  stricture  of,  418 


RADIAL  artery,  ligature,  45 
Radius,  excision,  1.S7 
Rauula,  361 
Rectum,  excision,  453 

operations  on,  446 

prolapse,  449 
Rhinoplasty,  278 
Ribs,  resection,  181 
Round  ligaments,  shortening,  584 
Rous:,  amputation  at  ankle,  98 


;  OALPINGECTOMY,  579 
U    Salpingo-oophorectomy,  579 
Scapula,  excision,  183 
Seminal  vesicles,  removal,  541 
Sciatic  artery,  ligature,  59 

nerve,  232 
Shoulder,  amputation  at,  80 

excision  of,  127 
Skin-grafting,  238 
Spinal  accessory  nerve,  229 
Splenectomy,  470 
Sponges,  preparation  of,  21 
Staphyloraphy,  345 
Sterilization,  26 
Sternum,  resection  of,  180 
Stomach,  operations  on,  412 
Strabismus,  operation  for,  332 
Subastragaloid  amputation,  94 
Subclavian  artery,  ligature,  36 
Superior  thyroid  artery,  ligature,  39 

maxillary  nerve,  219 
Supraorbital  nerve,  217 
Suprapubic  cystotomy,  534 
Sutures,  21 
Symblepharon,  303 
Syme,  amputation  at  ankle,  95 
Symphysiotomy,  586 


TALIPES,  osteotomy,  253 
Tarso-metatarsal  amputation,  90 
Temporal  artery,  ligature,  54    • 
Tenorrhaphy,  236 
Tenotomy,  233 
Thiersch,  skin-grafting,  238 
Thigh,  amputation,  114 
Thorax,  operations  on,  382 

paracentesis,  384 
Thyroid  artery,  ligature  of  inferior,  39 
superior,  39 

gland,  operations,  378 
Tibia,  osteotomy,  252 

resection,  190 
Tibial  artery,  ligature  of  anterior,  63 

posterior,  65 
Toenail,  ingrown,  245 
Toes,  amputation,  87 
Tongue,  excision,  355 

Kocher,  358 
Tonsils,  amputation,  344 
Torticollis,  229 
Tracheotomy,  367 
Trephining,  cranium,  197 

omega  flap,  200 

for  abscess,  211 

for  hemorrhage,  213 

to  reach  cerebellum,  212 
Trichiasis,  306 


ULNA,  excision,  187 
Ulnar  artery,  ligature,  46 
nerve,  231 
Uranoplasty,  351 
Ureter,  operations  on,  480 

wounds  of,  482 
Urethral  fistula.  503 
Urethroplasty,  505 
Urethroraphy,  505 
Urethrotomy,  external,  510,  543 
internal,  508 


598 


INDEX. 


Uterus,  amputation  of  gravid,  590 
of  cervix,  591 
laceration  of  cervix,  571 
prolapse  of,  567 
tumors  of,  5S6 


VAGINA,  atresia  of,  546 
>      narrowing  of,  567 

obliteration  of,  565 

prolapse  of  posterior  wall,  549 
Varicocele,  486 


Ventricles,  puncture  of,  213 
Vermiform  appendix,  409 
Vertebral  artery,  ligature,  40 
Vesico-vaginal  fistula,  559 

creation,  565 
Vesicles,  removal  of  seminal,  541 


WEB-FINGERS,  243 
Wrist,  amputation  at,  75 
excision  of,  140 
Wrv-neck,  229 


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A  SYSTEM  OF  PRACTICAL  MEDICINE  BY  AMERICAN 
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BUMSTEAD  (F.  J.)  AND  TAYLOR  (R.  W.).  THE  PATHOLOGY 
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Venereal  Diseases,  page  15. 

BURNETT  (CHARLES  H.).  THE  EAR :  ITS  ANATOMY,  PHYSI- 
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DALTON  ( JOHN  C).  A  TREATISE  <>N  HUMAN  PHYSIOLOGY. 
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DAVIS  (P.  H.).  LECTURES  ON  CLINICAL  MEDICINE.  Second 
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DAVIS'  (EDAVARD  P.).  A  TREATISE  ON  OBSTETRICS.  FOR 
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DERCUM  (FRANCIS  X.,  EDITOR).  A  TENT-BOOK  ON 
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DE  SCHWEFNITZ  (GEORGE  E.).  THE  TOXIC  AMBLYOPIAS. 
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DRAPER  (JOHNC).  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
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DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF 
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DUANE  (ALEXANDER).  THE  STUDENT'S  DICTIONARY  OF 
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leather,  $4.50. 
EDIS  (ARTHUR  W\).     DISEASES   OF   WOMEN.    A  Manual  for 

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ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY.  See  Ameri- 
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FARQUHARSON  (ROBERT).     A  GUIDE  TO  THERAPEUTICS. 

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FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE 
EAR.  Fourth  edition.  In  one  octavo  volume  of  391  pages,  with  73 
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FLEVT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND 
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<  Sloth,  si  ,50.    Also  bound  with  Clouston  on  Insanity. 

FOSTER  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  NVw 
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POWNES  (GEORGE).  A  MANUAL  OF  KLKMKNTARY  CHEM- 
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2  plates.     Cloth,  $3.75 ;  leather,  $4.75. 

FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  OR- 
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238  pages,  with  25  engravings  and  8  full-page  plates.  Cloth,  $2. 
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FULLER  (HENRY).     ON  DISEASES  OF  THE  LUNGS  AND  AIR ' 
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GANT  (FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  A 
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pages,  with  60  illustrations,  mostly  photographic.     Cloth,  $2.75. 

GD3NEY  (V.  P.).  ORTHOPEDIC  SURGERY.  For  the  use  of  Practi- 
tioners and  Students.     In  one  8vo.  vol.  profusely  illus.    Preparing. 

GOULD  (A.  PEARCE).  SURGICAL  DIAGNOSIS.  In  one  12mo. 
vol.  of  589  j>ages.     Cloth,  $2.  See  Student's  Series  of  Manuals,  p.  14. 

GRAY  (HENRY).  ANATOMY,  DESCRIPTIYE  AND  SURGICAL. 
Edited  by  T.  Pickering  Pick,  F.R.C.S.  A  new  American,  from  the 
thirteenth  English  edition,  thoroughly  revised.  In  one  imperial  octavo 
volume  of  1118  pages,  with  636  large  and  elaborate  engravings.  Price, 
with  illustrations  in  colors,  cloth,  $7 ;  leather,  $8.  Price,  with  illus- 
trations in  black,  cloth,  $6  ;  leather,  $7. 

GRAY  (LANDON  CARTER).  A  TREATISE  ON  NERYOUS  AND 
MENTAL  DISEASES.  For  Students  and  Practitioners  of  Medicine. 
New  (2d)  edition.  In  one  handsome  octavo  volume  of  72S  pages,  with 
172  engravings  and  3  colored  plates.  Cloth,  $4.75;  leather,  $5.75. 
Just  ready. 

GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY 
AND  MORBID  ANATOMY.  New  (7th)  American  from  the  eighth 
London  edition.  In  one  handsome  octavo  volume  of  595  pages,  with 
224  engravings  and  a  colored  jjlate.     Cloth,  $2.75. 

GREENE  (\VTLLL\M  H.).  A  MANUAL  OF  MEDICAL  CHEM- 
ISTRY. For  the  Use  of  Students.  Based  upon  Bowman's  Medical 
Chemistry.    In  one  12mo.  vol.  of  310  pages,  with  74  illus.   Cloth,  $1.75. 

GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES, INJURIES  AND  MALFORMATIONS  OF  THE  URINARY 
BLADDER,  THE  PROSTATE  GLAND  AND  THE  URETHRA. 
Third  edition,  thoroughly  revised  and  edited  by  Samuel  W.  Gross, 
M.D.     In  one  octavo  vol.  of  574  pages,  with  170  illus.     Cloth,  $4.50. 

HABERSHON  (S.  O.).  ON  THE  DISEASES  OF  THE  ABDOMEN, 
comprising  those  of  the  Stomach,  CEsophagus,  Caecum,  Intestines 
and  Peritoneum.  Second  American  from  the  third  English  edition. 
In  one  octavo  volume  of  554  pages,  with  11  engravings.     Cloth,  $3.50. 

HAMILTON  (ALLAN  McLANEi.  NERYOUS  DISEASES,  THEIR 
DESCRIPTION  AND  TREATMENT.  Second  and  revised  edition. 
In  one  octavo  volume  of  598  pages,  with  72  engravings.     Cloth,  $4. 

HAMDLTON  (FRANK  H).  A  PRACTICAL  TREATISE  ON  FRAC- 
TURES AND  DISLOCATIONS.  Eighth  edition,  revised  and  edited 
by  Stephen  Smith,  A.  M.,  M.  D.  In  one  handsome  octavo  volume  of 
832  pages,  with  507  engravings.     Cloth,  $5.50;  leather,  $6.50. 

HARDAWAY  (W.  A.).  MANUAL  OF  SKIN  DISEASES.  In  one' 
12mo.  volume  of  440  pages.     Cloth,  $3. 


Lea  Brothers  &  Co.'s  Publications. 


HARE  (HOBART  AMORY).     A  TEXT-BOOK  OF  PRACTICAL 

THEBAPEUTICS,  with  Special  Reference  to  the  Application  of 
Remedial  Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  "With  articles  on  various  subjects  by  well-known  specialists. 
New  (5th)  and  revised  edition.  In  one  octavo  volume  of  740  pages. 
Diagonal  Cloth,  $3.75  ;  leather,  $4.75.    Just  read)/. 

PRACTICAL  DIAGNOSIS.    THE   USE  OF  SYMPTOMS  IN 

THE  DIAGNOSIS  OF  DISEASE.  Handsome  octavo,  about  500 
pages,  richly  illustrated  in  black  and  colors.     Shortly. 

HARE  (HOBART  AMORY),  EDITOR.  A  SYSTEM  OF  PRAC- 
TICAL THERAPEUTICS.  By  American  and  Foreign  Authors.  In 
a  series  of  contributions  by  78  eminent  Physicians.  Three  large  octavo 
volumes  comprising  3544  pages,  with  434  engravings.  Price  per 
volume,  cloth,  $5;  leather,  SO;  half  Russia,  $7.  For  sale  by  sub- 
scription only.    Address  the  publishers. 

HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo. 
volume,  669  pages,  with  144  engravings.     Cloth,  $2.75;  half  bound,  $3. 

A  HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.    In  one 

12mo.  volume  of  310  pages,  with  220  engravings.     Cloth,  $1.75. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.     Comprising 

Manuals  of  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Prac- 
tice of  Medicine,  Surgery  aud  Obstetrics.  Second  edition.  In  one  royal 
12mo.  vol.  of  102S  pages,  with  477  illus.     Cloth,  $4.25 ;  leather,  $5. 

HAYEM  (GEORGES)  AND  HARE  (H.  A.)  PHYSICAL  AND 
NATURAL  THERAPEUTICS.  The  Remedial  Use  of  Heat,  Elec- 
tricity, Modifications  of  Atmospheric  Pressure,  Climates  and  Mineral 
Waters.  Edited  by  Prof.  H.  A.  Hake,  M.  D.  In  one  octavo  volume 
.     of  414  pages,with  113  engravings.     Cloth,  S3.    Just  ready. 

HERMAN  (G.  ERNEST).  FIRST  LINES  IN  MIDWIFERY.  In 
one  12mo.  vol.  of  198  pages,  with  80  engravings.  Cloth,  $1.25.  See 
Student's  Series  of  Manuals,  p.  14. 

HERMANN  (L.).  EXPERIMENTAL  PHARMACOLOGY.  A  Hand- 
book of  the  Methods  for  Determining  the  Physiological  Actions  of 
Drugs.  Translated  by  Robert  Meade  Smith,  M.  D.  In  one  12mo. 
volume  of  199  pages,  with  32  engravings.     Cloth,  $1.50. 

HERRICK  (JAMES  B.).  A  HANDBOOK  OF  DIAGNOSIS.  In 
one  handsome  12mo.  volume  of  429  pages,  with  SO  engravings  and  2 
colored  plates.     Cloth,  $2.50.     Just  ready. 

HLLL.  (BERKELEY).  SYPHILIS  AND  LOCAL  CONTAGIOUS 
DISORDERS.     In  one  Nvo.  volume  of  479  pages.     Cloth,  $3.25. 

HELLXER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES. 
Second  edition.  In  one  royal  12mo.  volume  of  353  pages,  with  two 
plates.     Cloth,  $2.25. 

HHiST  (BARTON  C.)  AND  PD3RSOL  (GEORGE  A.).  HUMAN 
MONSTROSITIES.  Magnificent  folio,  containing  220  pages  of  text 
and  illustrated  with  123  i-iigravings  and  39  large  photographic  plates 
from  nature.  In  four  parts,  price  each,  $5.  Limited  edition.  For  sale 
In/  subscription  only. 

HOBLYN  (RICHARD  D.).  A  IHCTK  >X  A  It  Y  <>F  TIIF  TFIt.MS 
QSED  IN  MKMCINK  AND  TIIF  ( '<  (LLATFILVL  S<  '1  FN<  IKS. 
In  one  liimo.  volume  of  520  double-columned  pages.  Cloth,  $1.50; 
leather,  $2. 

HODGE  (HUGH  D.).  ON  DISEASES  PECULIAR,  TO  WOMEN. 
INCLUDING  DISPLACEMENTS  OF  THE  UTERUS.  Second  and 
revised  edition.    In  one  8vo.  vol.  of  519  pp., with  illus.    Cloth,  $4.50 

HOFFMANN!  Kl  :i>l  IKK  K  j  AND  I'OWEIK  FREDERICK B.). 
A  MANI'AF  OF  CIIFMM'AL  ANALYSIS,  as  Applied  to  the 
Examination  of  Medicinal  Chemicals  and  their  Preparations.  Third 
edition,  entirely  rewritten  and  much  enlarged.  In  one  handsome  octavo 
volume  of  62]  pages,  with  L79  engravings.    Cloth,  $4.25, 

HOIiDEN  rljUTHHK).  LANDMARKS,  MEDICAL  AND  SURGI- 
CAL. From  the  third  English  edition.  With  additions  by  W.  W. 
Keen,M.D.    En  one  royal  l2mo.  volume  of  L48  pages.    Cloth,  Si. 


Lea  Brothers  &  Co.'s  Publications. 


HOLLAND  (SLR  HENRY).  MEDICAL  NOTES  AND  REFLEC- 
TIONS. From  third  English  edition.  In  one  8vo.  volume  of  493 
pages.    Cloth,  $3.50. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Prin- 
ciples and  Practice.  A  new  American  from  the  fifth  English  edition. 
Edited  by  T.  Pickering  Pick,  F.R.C.S.  In  one  handsome  octavo  vol- 
ume of  1008  pages,  with  428  engravings.     Cloth,  $6  ;  leather,  $7. 

A  SYSTEM  OF  SURGERY.  With  notes  and  additions  by  various 


American  authors.  Edited  by  Johx  H.  Packard,  M.  D.  In  three 
very  handsome  8vo.  volumes  containing  3137  double-columned  pages, 
with  979  engravings  and  13  lithographic  plates.  Per  volume,  cloth,  $6 ; 
leather,  $7  ;  half  Russia,  $7.50.    For  sale  by  subscription  only. 

HORNER  (WILLIAM  E.).  SPECIAL  ANATOMY  AND  HIS- 
TOLOGY. Eighth  edition,  revised  and  modified.  In  two  large  8vo. 
volumes  of  1007  pages,  containing  320  engravings.    Cloth,  $6. 

HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER.    In  one 

octavo  volume  of  308  pages.     Cloth,  $2.50. 

HUTCHINSON  (JONATHAN).  SYPHILIS.  In  one  pocket-size  12mo. 
volume  of  542  pages,  with  8  chronio-lithographic  plates.  Cloth,  $2.25. 
See  Series  of  Clinical  Manuals,  p.  13. 

HYDE  (JAMES  NEVINS).  A  PRACTICAL  TREATISE  ON  DIS- 
EASES OF  THE  SKIN.  Third  edition,  thoroughly  revised.  In 
one  octavo  volume  of  802  pages,  with  108  engravings  and  9  colored 
plates.  Cloth,  $5 ;  leather,  $6. 

JACKSON  (GEORGE  THOMAS).  THE  READY-REFERENCE 
HANDBOOK  OF  DISEASES  OF  THE  SKIN.  In  one  12mo. 
volume  of  544  pages,  with  50  engravings.    $2.75. 

JAMIESON  (W.  ALLAN).  DISEASES  OF  THE  SKIN.  Third 
edition.  In  one  octavo  volume  of  656  pages,  with  1  engraving  aud  9 
double-page  chromo-lithographic  plates.     Cloth,  $6. 

JONES  (C.  HANDFLELD).  CLINICAL  OBSERVATIONS  ON 
FUNCTIONAL  NERVOUS  DISORDERS.  Second  American  edi- 
tion.   In  one  octavo  volume  of  340  pages.     Cloth,  $3.25. 

JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE 
AND  PRACTICE.  Second  edition.  In  one  octavo  volume  of  549 
pages,  with  201  engravings,  17  chromo-lithographic  plates,  test-types  of 
Jaeger  and  Snellen,  and  Holmgren's  Color-Blindness  Test.  Cloth, 
$5.50 ;  leather,  $6.50. 

KING  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Sixth  edition. 
In  one  12mo.  vol.  of  532  pages,  with  221  illus.  Cloth,  $2.50. 

KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.    See  American 

Text-Books  of  Dentistry,  p  2. 

KLEIN  (E.).  ELEMENTS  OF  HISTOLOGY.  Fourth  edition.  In 
one  pocket-size  12mo.  volume  of  376  pages,  with  194  engravings. 
Cloth,  $1.75.     See  Student's  Series  of  Manuals,  p.  14. 

LANDIS  (HENRY  G.).   THE  MANAGEMENT  OF  LABOR.   In  one 

handsome  12mo.  volume  of  329  pages,  with  2S  illus.   Cloth,  $1.75. 

LA  ROCHE  (R.).  YELLOW  FEVER.  In  two  Svo.  volumes  of  1468 
pages.     Cloth,  $7. 

PNEUMONIA.    In  one  Svo.  volume  of  490  pages.     Cloth,  s.i. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C).  A  HANDY- 
BOOK  OF  OPHTHALMIC  SURGERY.  Second  edition.  In  one 
octavo  volume  of  227  pages,  with  G6  engravings.     Cloth,  S2.75. 

LAWSON  (GEORGE).  INJURIES  OF  THE  EYE,  ORBIT  AND 
EYE-LIDS.  From  the  last  English  edition.  In  one  handsome  octavo 
volume  of  404  pages,  with  92  engravings.     Cloth,  $3.50. 


10  Lea  Bkotheks  &  Co.'s  Publications. 


LEA  (HENRY  C.).  CHAPTERS  FROM  THE  RELIGIOUS  HIS- 
TORY OF  SPAIX;  CENSORSHIP  OF  THE  PRESS;  MYSTICS 
AND  ILLUMINATI ;  THE  ENDEMONIADAS ;  EL  SANTO  NINO 
DE  LA  GUARDIA;  BRIANDA  DE  BARDAXI.  In  one  12ino. 
volume  of  522  pages.     Cloth,  $2.50. 

LEA  (HENRY  C).  A  HISTORY  OF  AURICULAR  CONFESSION 
AND  INDULGENCES  IN  THE  LATIN  CHURCH.  In  three 
octavo  volumes.  Vols.  I.  and  II.,  1056  pages.  Each,  cloth,  $3.  Just 
ready.   Vol.  III.  shortly. 

FORMULARY"  OF  THE   PAPAL  PENITENTIARY.    In  one 

octavo  volume  of  221  pages,  with  frontispiece.     Cloth,  $2.50. 

SUPERSTITION  AND  FORCE ;  ESSAYS  ON  THE  WAGER 


OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND 
TORTURE.  Fourth  edition,  thoroughly  revised.  In  one  hand- 
some  royal  12mo.  volume  of  629  pages.  Cloth,  $2.75. 
—  STUDIES  IN  CHURCH  HISTORY.  The  Rise  of  the  Temporal 
Power — Benefit  of  Clergy — Excommunication.  New  edition.  In  one 
handsome  12mo.  volume  of  605  pages.     Cloth,  $2.50. 

AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 


IN  THE  CHRISTIAN  CHURCH.  Second  edition.  In  one  hand- 
some octavo  volume  of  685  pages.     Cloth,  $4.50. 

LEE  (HENRY)  ON  SYPHILIS.  In  one  Svo.  volume  of  246  pages. 
Cloth,  $2.25. 

LEHMANN  (C.  G.).  A  MANUAL  OF  CHEMICAL  PHYSIOLOGY. 
In  one  Svo.  volume  of  327  pages,  with  41  engravings.     Cloth,  $2.25. 

LEISHMAN  (WILLIAM).  A  SYSTEM  OF  MIDWIFERY.  Includ- 
ing the  Diseases  of  Pregnancy  and  the  Puerperal  State.  Fourth  edi- 
tion.  In  one  octavo  volume. 

LOOMIS  (ALFRED  L.)  AND  THOMPSON  (W.  GILMAN). 
A  SYSTEM  OF  PRACTICAL  MEDICINE.  In  Treatises  by  Amer- 
ican Authors.     In  very  handsome  Svo.  volumes  with  illus.     In  press. 

LUCAS  (CLEMENT).  DISEASES  OF  THE  URETHRA.  Preparing. 
See  Series  of  Clinical  Manuals,  p.  13. 

LUDLOW  (J.  L.).  A  MANUAL  OF  EXAMINATIONS  UPON 
ANATOMY,  PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDI- 
CINE, OBSTETRICS,  MATERIA  MEDICA,  CHEMISTRY,  PHAR- 
MACY AND  THERAPEUTICS.  To  which  is  added  a  Medical  For- 
mulary. Third  edition.  In  one  royal  12mo.  volume  of  816  pages,  with 
.!7<i  engravings.     Cloth,  $3.25 ;  leather,  $3.75. 

LUFF  (ARTHUR  P.).  MANUAL  OF  CHEMISTRY,  for  the  use  of 
Students  of  Medicine.  In  one  12mo.  volume  of  522  pages,  with  36 
engravings.     Cloth,  $2.    See  Student's  Series  of  Manuals,  p.  14. 

LYMAN  (HENRY  M.).  THE  PRACTICE  OF  MEDICINE.  In  one 
very  handsome  octavo  volume  of  925  pages,  with  170  engravings. 
Cloth,  $1.7."-;  Leather,  $5.75. 

LYONS  (ROBERT  D.).  A  TREATISE  ON  FEVER.  In  one  octavo 
volume  of  -Wi'J,  pages.    Cloth,  $2.25. 

>I\ISCH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA 
MEDICA.   New (6th) edition,  thoroughly  revised  by  II.  CO.  Maisch, 

Ph.G.,  I'll.  D.    Ii 'very  handsome  12mo.  volume  of  509  pages,  with 

285  engravings.    Cloth,  $3. 

MANUALS.  See  Stuck  nt's  Quiz  Series,  p.  14,  Student's  Series  of  Maim- 
ah,  p.  14,  and  Series  of  CUmAcal  Manuals,  |».  13. 

MARSH  (HOWARD).  DISEASES  OK  THE  JOINTS.   In  .me  12 

volume  of  468  pages,  \\  ith  6  I  engravings  and  a  colored  plate.  Clo1  b,  $2. 
See  Series  of  Clinical  Manuals,  p.  13. 

MAY  (G.  11.!.  MANUAL  OF  THE  DISEASES  OF  WOMEN.  For 
tli<-  use  of  Students  and  Practitioners.  Second  edition^  revised  by  L. 
s.  Rat/.  M.  I>.  In  one  L2mo.  volume  of  360  pages,  with  31  engrav- 
ings.   Cloth,  $1.75. 


Lea  Brothers  &  Co.'s  Publications.  11 

MITCHELL  (JOHX  K.).  REMOTE  CONSEQUENCES  OF  IN- 
JURIES OF  NERVES  AND  THEIR  TREATMENT.  In  one 
handsome  12mo.  volume  of  239  pages,  with  12  illustrations.  Cloth, 
$1.75.     Just  ready. 

MORRIS  (HENRY).     SURGICAL  DISEASES  OF  THE  KIDNEY. 

In  one  12mo.  volume  of  554  pages,  with  40  engravings  and  6  colored 
plates.     Cloth,  $2.25.     See  Series  of  Clinical  Manuals,  p.  13. 

MORRIS    (MALCOLM).      DISEASES    OF    THE    SKIN.  _    In  one 

square  Svo.  volume  of  572  pages,  with  19  chromo-lithographic  figures 
and  17  engravings.     Cloth,  $3.50. 

MULLER  (J.).  PRINCIPLES  OF  PHYSICS  AND  METEOROL- 
OGY.    In  one  large  Svo.  vol,  of  623  pages,  with  538  cuts.  Cloth,  $4.50. 

MUSSER(JOHNH-).   A  PRACTICAL  TREATISE  ON  MEDICAL 

DIAGNOSIS,  for  Students  and  Physicians.  In  one  octavo  volume 
of  873  pages,  illustrated  with  162  engravings  and  2  colored  plates. 
Cloth,  $5  ;  leather,  $6. 

NATIONAL  DISPENSATORY.  See  Stille,  Maisch  &  Caspari,  p.  14. 

NATIONAL  MEDICAL  DICTIONARY.     See  Billings,  p.  3. 

NETTLESHIP  (E.).  DISEASES  OF  THE  EYE.  Fourth  American 
from  fifth  English  edition.  In  one  12mo.  volume  of  504  pages,  with 
164  engravings,  test-types  and  formulae  and  color-blindness  test. 
Cloth,  $2. 

NORRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF 
OPHTHALMOLOGY.  In  one  octavo  volume  of  641  pages,  with  357 
engravings  and  5  colored  plates.     Cloth,  $5  ;  leather,  $6. 

OWEN    (EDMUND).      SURGICAL    DISEASES    OF    CHILDREN. 

In  one  12mo.  volume  of  525  pages,  with  85  engravings  and  4  colored 
plates.     Cloth,  $2.     See  Series  of  Clinical  Ma/rmals,  p.  13. 

PARK  (ROSWELL,  EDITOR).     TREATISE  ON  SURGERY.     BY 

American  Authors.  In  two  very  handsome  octavo  volumes  of  about 
800  pages  each,  profusely  illustrated  in  black  and  colors.     Shortly. 

PARRY  (JOHN  8.).  EXTRA-UTERINE  PREGNANCY,  ITS 
CLINICAL  HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREAT- 
MENT.    In  one  octavo  volume  of  272  pages.    Cloth,  $2.50. 

PARVTN  (THEOPHILUS).  THE  SCIENCE  AND  ART  OF  OB- 
STETRICS. New'  (3d)  edition.  In  one  handsome  octavo,  volume  of 
677  pages,  with  267  engravings  and  2  colored  plates.  Cloth,  $4.25 ; 
leather,  $5.25. 

PAVY  (F.  W.).  A  TREATISE  ON  THE  FUNCTION  OF  DIGES- 
TION, ITS  DISORDERS  AND  THEIR  TREATMENT.  From  the 
second  London  edition.     In  one  Svo.  volume  of  238  pages.     Cloth,  $2. 

PAYNE     (JOSEPH    FRANK).       A    MANUAL    OF    GENERAL 

PATHOLOGY.  Designed  as  an  Introduction  to  the  Practice  of  Medi- 
cine. In  one  octavo  volume  of  524  pages,  with  153  engravings  and 
1  colored  plate.     Cloth,  $3.50. 

PEPPER'S  SYSTEM  OF  MEDICINE.     See  p.  2. 
PEPPER  (A.  J.).     FORENSIC  MEDICINE.    In  press.    See  Student's 
Series  of  Manuals,  p.  14. 

SURGICAL  PATHOLOGY.    In  one  12mo.  volume  of  511  pages, 

with  81  engravings.   Cloth,  $2.   See  Student's  Series  of  Manuals,  p.  14. 

PICK  (T.  PICKERING).      FRACTURES  AND  DISLOCATIONS. 

In  one  12mo.  volume  of  530  pages,  with  93  engravings.  Cloth,  $2. 
See  Series  of  Clinical  Manuals,  p.  13. 

PIRRIE  (WILLIAM).     THE  PRINCIPLES  AND  PRACTICE  OF. 

SURGERY.  In  one  octavo  volume  of  7S0  pages,  with  316  engravings. 
Cloth,  $3.75. 


12  Lea  Brothers  &  Co.'s  Publications. 


PLAYFAIR  (W.  S.).  A  TREATISE  OX  THE  SCIENCE  AND 
PRACTICE  OF  MIDWIFERY.  Sixth  American  from  the  eighth 
English  edition.      Edited,  with  additions,  by  R.  P.  HARRIS,  M.  D. 

In  one  octavo  volume  of  697  pages,  with  217  engravings  and  5  plates. 
Cloth.  $4  ;  leather,  $5. 

THE  SYSTEMATIC  TREATMENT  OF  NERVE   PROSTRA- 


TION AND  HYSTERIA.     In  one  12mo.  vol.  of  97  pp.     Cloth,  $1. 

POLITZER  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE 
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QUIZ  SERIES.     See  Student's  Quiz  Series,  p.  14. 

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YEAR-BOOK  OF  TREATMENT  FOR  1896.  A  Critical  Review  for 
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YEAR-BOOKS  OF  TREATMENT  FOR  1891,  1892  and  1893,  similar 
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above,     li'ino.,  320-341  pages.     Limp  cloth,  $1.25. 
YEO  (I.  BURNEY).     FOOD   IX    IIKATII   AND   DISEASE.    In  one 

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A    MANUAL   OF   MEDICAL  TREATMENT,  OR  CLINICAL 

THERAPEUTICS.  Two  volumes  containing  L275pages.  (Moth,  $5.50. 
YOUNG  (JAMBS  K.).    ORTHOPEDIC  SURGERY.     In    one    8vo. 

volume  of  17.",  pages,  with  286  illustrations.    Cloth,  $4;  leather,  $5. 


COLUMBIA   UNIVERSITY 

This  book   is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

c20'eae)MBo 

RD31 

Stimson 


St5 
1895 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD  31  St5  1895  C.1 

A  manual  of  operative  surgery. 


2002109255 


